Questions marked with a * are required
PAL Program Outreach Request Form
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.  Because the PALS are a student lead organization, presentation requests will only be honored during the academic calendar year.  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 PALs reserve the right to provide outreach programming to Virginia Tech affiliated departments, organizations, and persons. 
Name of contact person
Email of contact person
Phone Number:
Organization or department requesting program
What type of outreach are you looking for?
Which presentation(s) would you like to request?: (For sessions lasting 1 hour or longer, you may select up to two presentations.)
Today's date
Desired program date(s).  Please note, it may be helpful to list a few potential dates, as scheduling conflicts with our PAL members can make it difficult to fit in every presentation. 
Start and end time(s) of program
How long would you like this presentation/session to last?
Program location (Please indicate Virginia Tech location or Zoom)
Expected number of participants
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.