Name
*
First Name
Last Name
Your Role/Title
*
Organization Name
*
Email
*
Phone
(###)
###
####
Social Media (if applicable)
Event Name
*
Type of Engagement
*
Keynote
Workshop/Seminar
Panel Participation
Podcast/Interview
Consulting Session
Other
Topic or Theme You'd Like Me to Address
*
Audience Description (Who will be attending? Profession, background, age range, estimated size, etc.)
*
Why You're Reaching Out to Me Specifically (What drew you to my work or voice for this opportunity?)
*
Date(s) of Event or Preferred Timeframe
*
MM
DD
YYYY
Event Format
*
In-person
Virtual
Hybrid
Event Location (if applicable)
*
Length of Session Requested
*
20-30 minutes
45-60 minutes
Half Day
Full Day
Multi-session or Series
Other
Is there a budget allocated for this engagement?
*
Yes
No
We'd like to discuss options
If yes, please specify range
Under $1,000 (typically only available for short virtual events or mission-aligned nonprofit/educational orgs.)
$1,000-$2,500 (virtual workshops, panels, guest lectures.)
$2,500-$5,000 (keynotes, half-day trainings, custom-designed workshops.)
$5,000-$10,000 (full-day engagements, conferences, retreats, consulting + facilitation bundles.)
$10,000+ (multi-day events, travel-intensive engagements, organizational training series.)
Unsure - let's discuss what's possible.
Will this session be recorded, photographed, or shared publicly?
*
Yes
No
If yes, let me know your intended use so we can align expectations.
Is there anything else I should know?
How soon would you like to hear from me or my team?
*
ASAP
Within a week
Just exploring options for now
