Speaker and Event request form

Speaker and Event Request Form
Name

First NameLast Name
E-mail
example@example.com
Phone Number

Area CodePhone Number
TELL US ABOUT YOU!
Name of Organization/ Group
What type of event are you interested in?

Speaker (Teaching or informational presentation)Workshop (Interactive with activities and discussion)Processing Group (Facilitated topical discussion)Crisis Management (sudden event response)Other
What is your event?
Leadership training, Symposium, Teacher In-service, Parent resourcing, etc.
Overall theme of event?
Wellness, Leadership, Boundaries, Parenting, etc
Who is the primary audience?
Parents, students, therapists, pastors, single mothers, etc
Expected size of audience?
When is your event?
Where is your event being held?
How much time is expected of us at your event?

HOW CAN WE HELP?
Topic(s) you would like for us to cover
Provide three to five bullet points of areas you want to make sure we touch on.
What are some challenges you are seeing that you would like to overcome, (if applicable. This may be covered in above question)
What is your speaker budget for this event?
Is there a particular presenter you are inquiring about? Select all that apply if more than one.

Matthew LaGrange, PhDMelissa Lawver, MA, LPC-SJody Jones, MA, LPCAnyone who meets the criteriaOther
If "OTHER" please clarify.
Is there a required credentialing, certification, or experience you need in a speaker?
Anything else we need to know?

Thank you for showing an interest in the work we do and our professional team at His Story. We will review the information you are submitting and get back to you as to our ability ot serve you well. If this is not something we feel we do well, we will let you know and likely refer you to someone in our networked industry that we feel is more appropriate for you event and needs. Our mission is to make mental health care available to those on the community who need it and we are thankful for your part in that mission by hosting events and creating oportunties to make connections. Feel free to reach out at anytime to our director team if needed.

Matthew LaGrange, PhD is our Executive Director at Matthew@his-story.org

Melissa Lawver, MA, LPC-S is our Clinical Director at Melissa@his-story.org

Jody Jones, MA, LPC is our Director of Operations and Business Development at Jody@his-story.org.

Our webiste is www.his-story.org

Talk to you soon!
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