Interview/Project Request Form

Use this form if you need a clinician or a professional member of our staff to answer questions for a media interview.

Make sure to submit the form at least 2 weeks in advance (Please note that if you want to interview a clinician you must submit the form at least 3 weeks in advance). Requests that are placed after that time frame will be discarded due to high demand and scheduling purposes.

Name
Today's Date Today's Date / MM / DD YYYY
Project Deadline Project Deadline / MM / DD YYYY

Please note you must submit this form two to three weeks in advance of your deadline. We cannot guarantee an answer otherwise due to high demand for our services. Thank you for your understanding.
Which organization are you affiliated with?

Which organization are you affiliated with? PantherNow South Florida Media Network (FIU Journalism + Media) FIU External Relations Miami local media (i.e. Miami Herald) Other Other
Whom would you like to interview?

Whom would you like to interview? Master's Level Clinician Doctorate Level Clinician Director Front Desk Staff Anyone belonging to the department Other Other
Affiliation

Affiliation Counseling & Psychological Services (CAPS) Victim Empowerment Program (VEP) Either or

Choose CAPS for mental health including anxiety, depression, stress, time management, alcohol or drug abuse, etc.

Choose VEP for sexual assault, relationship abuse, stalking, or other types of victimization.
Interview Questions (Please make sure these are not already being answered by a visit to our website caps.fiu.edu or vep.fiu.edu)

Due to high demand and scheduling purposes we ask that you send us the questions ahead of time.
Does your interview need to be recorded? (Please note this may affect the viability of the interview)

Does your interview need to be recorded? (Please note this may affect the viability of the interview) Yes No
Can your interview be facilitated by:

Can your interview be facilitated by: Phone Email In person Videoconferencing Any of the above
Your Phone Number: Your Phone Number: - ### - ### ####
Your Email Address (We will confirm the viability of the interview only by e-mail):
Availability

Please provide us with several dates and times when you could be reached by our staff.
Please provide us with any other information you would like us to have (if applicable):