Suicide and Violence Prevention

If you or someone you know is experiencing a crisis, DO NOT use this form as a means of seeking help; call 954-424-6911 (Henderson Student Counseling Services) or 911.

Today's Date*

Department Contact's Full Name*

( Note: The contact person is the person from your department who we should contact for purposes of scheduling)

Extension*(i.e. 21005)

Email Address*

Facilitator Name*

( Note: The facilitator is the person from your department who will be present for the presentation. The facilitator must be on site ½ hour before and during the presentation).

Facilitator Extension*(i.e. 21005)

Preferred Presentation Date*(Request at least 2 weeks in advance) (i.e.12/15/2009)

Start Time Requested*(SVP presentations are 40-60 minutes in length for non-clinical groups and 60-95 minutes for clinical groups)

Presentation Location:

Bldg*

Floor*

Room #*

Audience*

Clinical Students

Faculty

Non-Clinical Students

Staff

Academic Center

Program

Number of Participants*

Type of Presentation Requested*

Suicide and Violence Prevention

Stress Management

Other

Note: SVP presentations are facilitated through Power Point. You are responsible for providing the equipment required (i.e. computer and projector). If you have any questions, please email SVP or call (954) 262-5789.