Speaking Services Request

Speaking Services Request Form

Please fill in the form below.
- Organization Name*
- Primary Contact Name*
  
  First NameLast Name
- Primary Contact Email*
- Primary Contact Phone Number*
- Organization Type*
  
  Hospital / HealthcareUniversity / CollegeSchool / DistrictPrivate PracticeNonprofitConference / Event OrganizerMedia OutletOther
- Organization Location (City, State/Province, Country):*
- Specific Dates/Timeframe you are seeking to schedule**
- What type of speaking engagement are you requesting?*
  
  Interview (radio, podcast, media)Event / Conference PresentationOnline Webinar (30 min - 1 hour)Workshop / Training (2 - 8 hours)Course (multi‑session)Private Course (Mentorship Level 1, School-Based Intensive, Praxis, Foundations of Development)Other
- Is this request for:*
  
  Existing STAR contentCustom contentUnsure — would like to discuss optionsOther
- Link to available offerings:
  Consultation/Speaking Services
- Requested topic or focus area*
- Primary learning goals / objectives for your audience*
- Any specific challenges or needs you want this presentation to address?*
- Who will be attending?*
  
  Occupational Therapists / OT AssistantsPhysical Therapists / PT AssisiatnsSpeech-Language PathologistsMental Health ProvidersNurses / Behavioral Health TechsEducators / School StaffParents / CaregiversAdministratorsGeneral PublicOther
- Estimated number of attendees*
- Would you like to offer AOTA or ASHA CEUs for this course? (Additional fee applies)*
  
  YesNoNot sure - would like to discuss
- Do you have or have access to an established mailing list to utilize in marketing this program locally?*
  
  YesNoN/A (will not be marketing outside my own organization)
Should be Empty:

Speaking Services Request Form