Speaker Form for Dr. DeAvila Ford, DBH, LCSW
Greetings!

If you are interested in booking Dr. DeAvila Ford as a speaker for an upcoming event with your organization, then please fill out this brief form.

Please give Dr. Ford approximately 48 hours to contact you via the email you provide below to schedule a FREE 15-minute consultation. During this consultation, discussion points will include the information gathered from this form, pricing, materials needed, etc. 

Thank you in advance for your consideration!
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Email *
FIRST AND LAST NAME *
PHONE NUMBER (INCLUDE AREA CODE) *
WHEN IS THE SPEAKING ENGAGEMENT? (DATE AND TIME)
 *
WHAT TYPE OF SPEAKING ENGAGEMENT IS THIS? BRIEFLY DESCRIBE.
 *
HOW LONG DO YOU NEED ME TO SPEAK?
 *
DO YOU WANT ME TO STAY AFTER OR ARRIVE EARLY? HOW MUCH ADDITIONAL TIME?
 *
IS THERE A COST FOR ATTENDEES? IF SO, HOW MUCH?
 *
WHAT IS THE ANTICIPATED SIZE OF THE AUDIENCE?
 *
GIVE ME AN IDEA OF THE AUDIENCE. 
DEMOGRAPHICS (ETHNICITY, GENDER, PROFESSIONALS ETC...)?
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GIVE ME A DESCRIPTION OF THE VENUE.
 *
WHAT TOPIC WOULD YOU LIKE ME TO COVER? *
DO YOU OFFER AN HONORARIUM? *
Based on my schedule in the above description, what days and times are you free to meet for a consultation?
 *
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