Name of Person Completing Form *

First Name

Last Name

Contact Person's Phone Number. *

(###)

###

####

Date *

What is the date of the event? It is recommended you request services approximately 3 weeks to 2 months in advance to allow for adequate preparation as needed. Please call if you are requesting a service sooner than this time frame.

MM

DD

YYYY

Service you are requesting: *

Please select all that apply

Participation on a Panel

Provide a Workshop/Class

Speaking Request

General EAP Contract Services

Specialized EAP Contract Services

Facilitating "Difficult Conversations"

Other

Requested Topic *

Wellness

Anxiety

Being in the Counseling Field/Therapy

Self Care

Racial Trauma

Depression

Other

Are attendees paying to be at this event?

Yes

No

Will the event be recorded? *

Yes

No