Speaker Interest Form

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Speaker Interest Form

Thank you for your interest in being a speaker at the 2024 NATI Healing & Wellness Institute. Please complete the following information. You will be provided with additional instructions upon receipt. Deadline to submit this form is March 29, 2024. Thank you.

Email: *

Full Name: *

Phone Number: *

Organization *

Title of Presentation

Provide a short bio (you will have an opportunity to provide a full bio at a later time)
*

Option 1

Clear selection

Brief description of your presentation (you will provide detailed information at a later time).
*

Learning Objectives: List three things that the attendee will take away following your presentation
*

TRACK: Select the track this presentation fall under
*

Cultural Competency/Awareness

Addiction/Process Addictions

Recovery

Peer Recovery

Clinical Skills/Management/Administration

Professional

Pharmacology

Co-Occurring Disorders

Self-Care/Wellness

Time Allotment: How much time do you require for your presentation?
*

60 minutes

90 minutes

120 minutes

Set Up
*

Classroom (rows of tables)

Theater (rows of chairs, no tables)

Circle of Chairs (interactive)

Rounds of 8 or 10 (great for discussions)

Audio Visual
*

Podium and Microphone (free)

Screen, Laptop, LCD Projector (free)

Flip Chart and Markers (free)

Wireless Microphone ($150 each, paid for by speaker)

Required

Submit

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