Speaking Questionnaire
Thank you for your interest in booking Jasmine Cobb, LCSW-S, our Grief Specialist, as a speaker for your event. We are eager to learn more about it. Please take a moment to provide the details requested below.

Please note that Jasmine is unable to fulfill unpaid requests. This decision is part of her commitment to oppose the expectation that women of color frequently face to perform unpaid labor.
登入 Google 即可儲存進度。瞭解詳情
電子郵件 *
How did you hear about us? *
Name and Title of Contact Person *
Telephone number *
Name of Organization *
Organization Website *
Organization's status:
 *
EVENT NAME *
EVENT DATE *
MM
/
DD
/
YYYY
EVENT WEBSITE *
WHAT TYPE OF SPEAKING ENGAGEMENT IS THIS? BRIEFLY DESCRIBE.  *
HOW LONG DO YOU WANT ME TO SPEAK? *
WHAT DO YOU WANT  ATTENDEES TO GET OUT OF YOUR EVENT?
 *
CONFIRMED SPEAKERS *
OTHER SPEAKERS/ INVITED GUESTS *
EVENT SPONSOR(S) *
Type of presentation requested:
 *
必填
DO YOU WANT ME TO STAY AFTER OR ARRIVE EARLY? HOW MUCH ADDITIONAL TIME?
 *
WHAT IS THE ANTICIPATED SIZE OF THE AUDIENCE?
 *
IS THERE A COST FOR ATTENDEES? IF SO, HOW MUCH?
 *
BUDGET FOR REQUESTED SPEAKER/ PRESENTATION:
 *
GIVE US AN IDEA OF THE AUDIENCE? DEMOGRAPHICS (ETHNICITY, GENDER, PROFESSIONALS, ETC...)? 
 *
GIVE US AN IDEA OF THE VENUE
 *
IT IS OUR UNDERSTANDING THAT YOU WOULD LIKE JASMINE TO COVER THESE SPECIFIC AREAS
 *
ARE YOU ABLE TO PRINT HANDOUTS FOR THE AUDIENCE?
 *
ARE YOU ABLE TO VIDEOTAPE OR RECORD THE SPEAKING EVENT?
 *
WILL YOU ALSO PAY FOR TRAVEL?
 *
WILL YOU ALSO PAY FOR ACCOMMODATIONS?
 *
WILL ANY MEDIA OUTLETS BE PRESENT?
 *
CAN PRODUCTS BE SOLD AT THIS EVENT?
 *
ADDITIONAL COMMENTS/INFO ABOUT THE EVENT *
*PLEASE NOTE*
POSSIBLE TOPICS CAN BE PROVIDED BUT IF YOU GIVE A BRIEF DESCRIPTION OF WHAT ISSUES NEED TO BE ADDRESSED, THE TALKING POINTS CAN BE TAILORED TO YOUR AUDIENCE.
提交
清除表單
請勿利用 Google 表單送出密碼。
reCAPTCHA
隱私權條款
這份表單是在 Visual Healing Therapeutic Services 中建立。 檢舉濫用情形
Google 表單