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Workshop Request Form

Program Requests

Thank you for your interest in an outreach workshop/program. At this time in the semester CAPS experiences a very high clinical demand for our services. As a result, our staff are focused on the provision of therapy services through the end of the spring semester, which precludes the delivery of outreach programming.

Given the nature of your request it is suggested that you contact one of the following departments on campus to see if they can fulfill your request:

  1. Wellness Programs at the CoRec. Here is a link for their request page: https://purdue.qualtrics.com/SE/?SID=SV_3qstl9oXIhRPMmF
  2. The Academic Success Center (KRAC 4th floor) 494-9328. Email requests to academicsuccess@purdue.edu

Contact Information

Today's Date

First and Last Name (*)

Phone Number (*)

Email Address (*)

Class or Organization Name (*)

Contact me via:

Program Information

Brief Description of Program Topic (*)

Requested Dates/Times (*)

Programs are only held Monday through
Thursday between 8:00am and 8:00pm.

Two week notice is required.


Location Where Program Will Be Held (*)

Desired Length of Program:

Number of People Expected at Program:

Marketing Information

How will the program be advertised?  (Check all that apply)

Table Tents
Word of Mouth
Other (Please identify) 

Are you willing to be involved in the planning and/or implementation of the program?

Yes No

Additional Information

Please provide any additional information that will help us facilitate your request: 

Submit or Reset Form

After pressing the Submit button below your information will be sent to the Coordinator of Outreach and Consultation in the form of an email. Dr. Don will contact you within one week of your submitting the request.

Thank you very much for completing this on-line outreach request.