Outreach Request Form

Please complete the form below to secure a workshop or presentation on various mental health topics. Requests for outreach events can only be made by an UH affiliate; event location must be on the University of Houston main campus. You may also email Nadine Dimaliwat at mfdimali@central.uh.edu. Please give at least a two week notice prior to a scheduled event.

Note: Due to volume of clinical responsibilities, CAPS may not be able to commit to all requests; however all requestors will receive a response.

Contact Name

Affiliation (check only one)

UH Department
UH Student Organization
UH Individual (staff/faculty/student)

Contact Email

Contact Phone

Please select Presentation Topic

Sexual/Physical Assault
Stress Management
Relationship Issues
Eating Issues/Disorders
Gender Issues
Diversity Issues
Substance Use/Abuse
Conflict Management
Suicidality (QPR training)
Self Harm
Other (please specify below)

Estimated Number of Attendees

Type of Audience (check all that apply)

Faculty / Staff

Preferred Date of Presentation

Start Time of Presentation

Approximate Duration of Program (optional)

Location of Presentation (must be on the UH Main campus)

Is audio visual equipment available in the room?