Speaker Request Form

Brittany is a therapist, speaker, educator and author. She welcomes the opportunity to encourage, inspire and educate others regarding all things mental and emotional health related. Please complete the following information regarding your request to have Brittany speak at your upcoming event. For any other business inquiries still complete this form. Brittany can not wait to connect with you! Upon completing the form, we will get back to you within 24 to 48 hours in regards to your event. Due to Brittany’s schedule we ask that you give us at least 30 to 60 day's notice prior to your event. Thank you in advance.

Please complete the form below

Name

First Name

Last Name

Email Address

Company/Organization

Name of Event*

Address Location *

Date and Time of Event*

Type of Event *

Expected Number of Attendees*

Are you charging attendees? If so, how much?*

What is your speaker budget?*

Your Contact Number*

How would you like Brittany to contribute to your event?*

Keynote Speaker

Workshop Facilitator

Panelist

Host

Trainer

Other

Please specify Other:

How long will you need Brittany to speak?*

Will Brittany be able to promote her products, books or services?*

Will travel accommodations be offered?* (Brittany is located in NJ)

Any additional information that you would like for me to know or consider?