Office of Health and Counseling Services

Health and Counseling Services Outreach Request Form

You may submit the following form to the Office of Health and Counseling Services for an outreach request. Please submit your request at least 10 business days before scheduled event.

Outreach requests are available to all students, faculty, and staff. All requests will be screened by the outreach coordinator and you will be contacted by outreach staff regarding the request. Approval of requests are contingent upon scheduling, availability of staff, and type of request submitted.

Contact Person's Name(Required)
Contact Person's DSU Email(Required)
Contact Person's Affiliation with Delta State University(Required)
Date of Event(Required)
Event Start Time(Required)
Event End Time(Required)
Audience (Select all that apply)
Type of Outreach Request:
This field is for validation purposes and should be left unchanged.