Community-Engagement-and-Intervention-Request-Form_2

Community Engagement and Intervention Request Form Please Note: All sections of the form MUST be completed in order for your request to be processed Organization Name Contact Person Contact Email & Phone Number Date of Event & Location Event Start Time & Duration # of People Attending How are you promoting this event? Students Audience (Select as many as apply) Faculty Staff Other If Other (Please be as specific as possible): Topic Experiences, concerns/observations that led to this request What have you already done to address this topic with your group? Level of CAPS Involvement Goals of involvement of CAPS in this program/activity Please explain how this particular topic aligns with the needs/priorities of the audience identified above o Request CAPS staff to participate in an event planned by person/organization issuing this request (Panel, Q&A, etc.) o Request CAPS staff provide a presentation o Request CAPS staff to lead or facilitate a group activity (Mindfulness, stress management, etc.) o Other: _ Which of the following CAPS, Campus Life, or Emory University priorities would meeting this request help us to achieve as a community? (select as many as apply) 1) Increase awareness/understanding of services provided by CAPS and the role CAPS plays in the Emory University community 2) Increase awareness/understanding of an emotional/psychological or student development issue/struggle 3) Help create and/or maintain a space for students to engage in community on issues and experiences facing them, toward building support and creating solidarity 4) To introduce skills and practices that enable students and communities to address challenges, build resilience, and/or Consultation Agreement enhance thriving Checking this box indicates that you agree to a brief consultation with the CAPS staff member(s) assigned to your request so that your needs can be clarified and any questions can be addressed Outreach is a high priority here at CAPS, as it helps us address the needs of the Emory community, especially those that are related to the struggles that lead to student impairment or comprise student safety We strive to meet as many of the requests as possible; however, because of the high demand for outreach services, we will prioritize those that articulate alignment with the goals of CAPS and the most well-considered requests as indicated on this request form Please return this form via email to Elizabeth Neri, LCSW, at elizabeth.neri@emory.edu You will receive a response via email or phone within three business days after your form is processed