Chacruna General Speaking Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out this form for any speaking requests (podcasts, interviews, etc.) for the Chacruna Institute for Psychedelic Plant Medicines. Once you have completed and submitted, we will follow-up with you through email.

Email *

Name *

Phone Number *

Type of request (podcast, interview, etc): *

Title of the event: *

Topic of the event: *

Date of the event: *

Format or location? *

Name of outlet, company, or organization running the event:

Website for the event and/or organization: *

Expected audience size: *

Any deadlines to be aware of?: *

Who is this request for?: *

Has this person (or these people) already agreed to the request? *

Yes

Other:

If your preferred source is unavailable at this time, what is your alternative proposal? *

Is there a preparation meeting required? *

Is there an honorarium? If yes, what is the honorarium amount offered? *

Will you cover the cost of travel? *

Will you cover the cost of lodging? *

Will the public pay to access this event? If so, how much does it cost? *

Does your event offer scholarships or sliding scales? Please specify:
*

Will the event be recorded? If so, do you plan to use or sell the recordings in future occasions? *

Please provide any additional details regarding your request: *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Chacruna Institute for Psychedelic Plant Medicines.

Does this form look suspicious? Report

Forms