木瓜影院 | Student Wellness Center -Program Request Form

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    • Program Request Form

    The multi-disciplinary team at the Student Wellness Center offers outreach and wellness education opportunities to the 木瓜影院 community through presentations, workshops, and training. Our team collaborates with student organizations and faculty/staff departments to address areas impacting overall student mental health and wellbeing. Team members welcome collaborative programs as well as visits to classrooms, student organizations and athletic teams to share resources and promote wellness topics.

    To request a program, check areas of topic interest below and complete the form. Submissions are requested a minimum of two weeks prior to the proposed program date. Confirmation of the request will be made within one week. If not feasible, an explanation will be made and/or offering of an alternative day and time.


    Applicant Information

    Topic Areas (select all that apply):  

     Overview of Student Wellness Center Services and TimelyCare Telehealth
     Stress Management, Self-Care & Balance
     Self-Esteem & Confidence
     Academic Motivation
     Student Athlete Wellbeing and Performance
     Healthy Sleep
     Procrastination
     Perfectionism
     Test Anxiety
     Mindfulness & Meditation
     Sexual Health
     Alcohol/Substance Use Prevention, Relapse & Recovery
     Suicide Prevention
     Body Image, Relationship with Food, Eating Behavior
     Grief & Loss
     Healthy Relationships & Interpersonal Communication
     Identity & Development
     Domestic/Sexual Violence Prevention
     Neurodivergence & Mental Health
     Expressive Therapies (i.e., art, music, movement)
     Other (please describe more below)

    If you selected other, please describe the type of programming you are interested in:

    *First Name:
     
    *Last Name:
     
    *Address:
     
    *City:
     
    *State:
     
    *Zip Code:
     
    *Phone Number:
     
    *Email:
     


    Please provide information for an alternative contact

    *Alternate First Name:
     
    *Alternate Last Name:
     

    *    Alternate Email:
     
    *Alternate Phone Number:
     

    Please enter the date and time of the requested program

    *Program Date:

    *Program Time:

    Please provide an alternative date and time for requested program

    *Alternate Program Date:
      
    *Program Time:



    **Length of time requested for program (i.e., 30, 45 mins, 1 hour)?
     
    *Will we be expected to speak for the entire program?
     Yes
     No  
    If you responded 鈥渘o鈥� to the previous answer, what is our time allotment?

    *Please enter the location of your program. Include the building, room number and any special instructions that may be needed to gain entrance to the building


    *What is your role in campus community?
     Student
     Faculty
     Staff  

    *Is this presentation for a student organization?
     Yes
     No  

    If yes, what is the name of the organization?



    *What is the make-up of your audience (i.e. first-year, professors, athletes, etc.)?
     
    *Expected Attendance
     

    Please list any other special requests, questions, or concerns.

    Security Password (Please type the word ):




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