Speaker Requested
*
Please Select
Adam D. Powell, MSW - President & CEO
Jeannette Papadopoulos, M.ED - COO
Tracy Nichols, PHR - CHRO
Anthonia Ibe, CPA - CFO
Jeannea Busby - Chief Program Officer
Greg Southworth, LPC - Clinical Director
Curtisha Taylor, LCSW - Clinical Coordinator
Your Name
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First Name
Last Name
Your Email
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example@example.com
Your Phone Number
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Your Organization/Company
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Your Website
yoursite.com
Tell us more about your organization/company
Event Name
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Event Host(s)
Event Date
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Month
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Day
Year
Date
Event Time (start/end times)
Hour Minutes
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PM
AM/PM Option
Until
until
Hour Minutes
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Event Location
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Event Format (i.e. keynote speaker or panel, Q&A, etc.)
What topic(s) will the event focus on and/or are you interested in hearing about from our team?
Who is the primary audience and how many are you expecting in attendance?
Is there an honorarium in your budget for this event?
Purpose or goals of your event?
We welcome any additional comments, requests or notes here.
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