Speaking Services Request Form
Please fill in the form below.
SECTION 1 — Organization Information
Organization Name
*
Primary Contact Name
*
First Name
Last Name
Primary Contact Email
*
Primary Contact Phone Number
*
Organization Type
*
Hospital / Healthcare
University / College
School / District
Private Practice
Nonprofit
Conference / Event Organizer
Media Outlet
Other
Organization Location (City, State/Province, Country):
*
SECTION 2 — Engagement Details
Specific Dates/Timeframe you are seeking to schedule*
*
What type of speaking engagement are you requesting?
*
Interview (radio, podcast, media)
Event / Conference Presentation
Online 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 content
Custom content
Unsure — would like to discuss options
Other
Link to available offerings:
Consultation/Speaking Services
SECTION 3 — Topic & Goals
Requested topic or focus area
*
Primary learning goals / objectives for your audience
*
Any specific challenges or needs you want this presentation to address?
*
SECTION 4 — Audience Details
Who will be attending?
*
Occupational Therapists / OT Assistants
Physical Therapists / PT Assisiatns
Speech-Language Pathologists
Mental Health Providers
Nurses / Behavioral Health Techs
Educators / School Staff
Parents / Caregivers
Administrators
General Public
Other
Estimated number of attendees
*
Would you like to offer AOTA or ASHA CEUs for this course? (Additional fee applies)
*
Yes
No
Not sure - would like to discuss
Do you have or have access to an established mailing list to utilize in marketing this program locally?
*
Yes
No
N/A (will not be marketing outside my own organization)
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