COUNSELING SERVICES PRESENTATION REQUEST FORM

Please fill out the form and submit; you will be contacted once we receive your request.

Today's Date: (ex: xx/xx/xxxx)

Presentation Topic Wanted:

Expected Date for the presentation: (ex: xx/xx/xxxx)

Expected Time of day/evening for the presentation: (ex: 1:30-2:30 p.m.)

Name of class/group to whom this will be presented:
Number expected to attend (we request at least 10 participants)

Requested length of presentation:

Where the presentation will be held:

Name of Person making the request:

Your title/responsibility:

Office Phone:

Email address:

Briefly describe the purpose of the presentation:

Other pertinent information:

Contact phone us at 785-532-6927 or email us if questions.