Counseling and Prevention Resource Center
Indian Hills Community College * 525 Grandview Avenue Ottumwa, IA 52501 * 641-683-5152
Outreach and Prevention Programming Request
Date of Request: _____________________ Name of Requestor: __________________________________________
Organization, Department or Class needing Program: _______________________________________________________
Contact Person Name: __________________________________________ Phone: __________________________
Email Address: _____________________________________________________________________________________
Type of Outreach Program Needed: Desired Program Topic(s)/Material(s): ______________
CPRC Services Presentation __________________________________________________
Mental Health Emergency Response and Prevention Orientation __________________________________________________
Psychoeducational Presentation/Workshop/Training __________________________________________________
Psychoeducational Material Requested Length of Program: ____________________
Tabling Event Location of Program: ____________________________
Mental Health or Youth Mental Health First Aid class __________________________________________________
Other: ___________________________________________________________________________________________________
Date of Program (option to list a few possible dates, if flexible): _______________________________________________
Time of Program (option to list a few possible times, if flexible): _______________________________________________
Type of Audience/Program or Department:
Students: _________________________________
Faculty: ___________________________________
Staff: _____________________________________
Estimated Audience Size: ______________________
Addtl. Characteristics and/or Needs of the Audience:
___________________________________________
Other: ____________________________________
Was this request prompted by a particular situation or event in your program or department? If so, please briefly describe
the situation that led to requesting this program: __________________________________________________________
Audio/Visual Equipment Provided: Yes No Please Specify: _________________________________
Special Requests for Program: _________________________________________________________________________
STAFF USE ONLY:
Confirmed; Date ______________ Time ___________ Assignment _______________________________________
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