Questions marked with a * are required
Staff Outreach Request Form
Please note: if you are looking for the PAL outreach request form this is not the correct form to use. Please follow this link to get to the PAL outreach request form: https://virginiatech.questionpro.com/t/AYRhDZzDP8

If you would like to request a program please complete the form below.  Your request should be submitted at least one month in in advance unless it is an urgent need response.  We will contact you by phone or e-mail to confirm your request.  If you do not hear from us you can call us at 540-231-6557. Questions can be directed to emmahare@vt.edu for assistance. 
The Cook Counseling Center reserves the right to provide outreach programming to Virginia Tech affiliated departments, organizations, and persons. 
Name of contact person
Email of contact person
Phone Number:
Department requesting program
Select a program:
Today's date
Desired date of program
Start and end time of program
Program location (Please indicate Virginia Tech location or Zoom)
Expected number of participants
Have you already talked to a CCC staff member about your desired presentation? 
If you answered yes to the previous question, which staff member did you speak to?
By entering my initials, I recognize and understand that my email address is provided solely for inquiries about the Cook Counseling Center’s outreach services. I understand that this is not a form of contact for counseling or help in an emergency. If I do need counseling, I must call the center at 540-231-6557 during the day and after-hours to reach the on-call counselor. If you do not feel like you can keep yourself safe, call 911 to receive immediate help.