SOMA Coaching/Consulting/Speaking Form

Coaching/Mentoring Form:

Complete the information below.
Full Name *

First Name Last Name
Name of Organization
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
E-mail
example@example.com
Website
example@example.com
Type of Session or Event are you booking? *
How did you hear about us?
FREE 30 MINUTE CONSULTATION

If you'd like a FREE Consultation, please answer the questions below. Otherwise skip to the next section.
Consultation Area of Interest:

Coaching Consulting Training Event Coordination Mentoring Counseling Speaking
Book Appointment

PLEASE NOTE THE APPOINTMENT MUST BE MADE 72 HOURS IN ADVANCE. YOU WILL RECEIVE AN EMAIL CONFIRMATION OF YOUR SCHEDULED APPOINTMENT.
Date

Month Day Year
Date
Time

Hour Minutes

AM/PM Option

Upon the completion of booking your free appointment, scroll down and press “SUBMIT”.
Coaching

If you'd like to book a coaching session, please answer the questions below. Otherwise skip to the next section.
What is the subject you want to discuss?
What do you want to achieve from this session? *
What action did you take since our last session? What were your wins/challenges?
What do I want to be held accountable for? *
Speaking

Please answer the questions below.
Date

Month Day Year
Date of the event
Time

Time of the event Minutes

AM/PM Option
Who will be speaking?

Dr. Joseph Amos Dr. Kathy Amos Both
What type of event will you be hosting?
Event Theme:
Brief Description of Event:
Topic and Brief Description of What Dr. Joseph or Dr. Kathy is to Speak on:
How many guests do you anticipate on having?
Is the event online or onsite?
How long will Dr. Kathy or Dr. Joseph be speaking and what topic would you like her to speak on?
You will provide Dr. Joseph or Dr. Kathy with the following. Please check all that apply.

Lodging Travel (if more than 50 miles email kathy@somacc.net with details) Video/Audio Equipment needed for presentation Not Applicable
My Products
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30 Minute Coaching Session Select this option after your first free coaching session.
$ 100.00 Quantity 1 Hour Coaching Session

Speaking Onsite Speaking Engagement Per 30 minutes
$ 500.00 Speaking Time

Subtotal

$ 0.00

Tax

$ 0.00

Total

$ 0.00
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Coaching/Mentoring Form: