Speaking Engagement Intake Form

Name

First NameLast Name

Organization/Company:

Job Title:

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Website (if applicable):

Event Name:

Event Date (s)

Event Location/ Platform (in-person or virtual):

Expected Audience Size :

Audience Type (eg. students, employees, entrepreneurs)

Event Theme or Focus:

Desire Speaking Topic(s):

Custom Topic (please describe):

Preferred Duration:

Presentation Format:

Other (please describe):

Will audio/visual equipment be provided?

Is travel and accommodation covered (if in-person)?

Dress Code / Event Tone:

Other (please describe):

Speaking Budget Range :

Would you like to use the speaker's name, image, or biography for event promotion ?

Will the event be recorded or live-streamed ?

If Live-streamed (please specify distribution plans):

Please share any goals, expectations, or special request for the motivational talk:

How did you find out about our services?

My Products:

Nonprofit Speaking Event

$500 – $2,500 per event

Local schools, churches, nonprofits

Short talks (30–60 minutes)

Virtual or local travel only

$500.00 Quantity

Corporate Speaking Event

$5,000 – $20,000 per event

Corporate events, conferences, leadership retreats

Audience size: 100–500+

Specialized topics (leadership, resilience, DEI, sales motivation)

$5,000.00 Quantity

Fortune 500 Speaking Event

$25,000 – $50,000+ per event

Fortune 500 companies

National conferences

International Speaking

Often bundled with workshops, books, or consulting

$25,000.00 Quantity

Consultation 15 mins

Free Quantity

Virtual Keynote

30–60 minutes

- Customized presentation

- Audience-focused message

- Live virtual delivery.

Price Range: $750-$1000

$750.00 Quantity

In-Person Keynote

30–60 minutes

- Customized keynote presentation

- Pre-event planning consultation

- Audience engagement and Q&A, as agreed

Price Range: $1500-$2500

$1,500.00 Quantity

Keynote + Interactive Workshop

2–3 hours

- Keynote presentation

- Interactive learning activities

- Practical strategies and discussion $2500-$4000

$2,500.00 Quantity

Half-Day Speaking & Training

Up to 4 hours

- Multiple presentations or training sessions

- Customized content

- Group discussion and practical takeaways

Price Range: $3500-$5000

$3,500.00 Quantity

Total

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Payment Methods

AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

I understand that in order to be successful, it is vital to follow the plan agreed by both the life coach and the client.

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