Contact/Speaker Request Form
Please understand that this form is for speaking requests only. You acknowledge that therapy or counseling sessions cannot be requested here and must be scheduled through www.kingdomcreativecounseling.com. You understand that any counseling-related inquiries submitted via this speaker form will not be reviewed or responded to.
Sign in to Google to save your progress. Learn more
Email *
Dr. Samaria Colbert is a dynamic speaker, prolific Bible teacher, author, entrepreneur, and trainer with a heart for pouring into the lives of others. Whether you are looking to book her for a speaking engagement or have a unique business proposal, we invite you to complete the form below. We look forward to the possibility of a Kingdom connection and seeing how we can impact lives together.
Disclaimer Regarding Ministry & Honorariums: While Dr. Samaria requests a professional honorarium for her time and services, it is important to note that her ministry and spiritual gifts are never utilized for the purpose of soliciting funds or financial manipulation. Her mission is strictly focused on the healing of individuals and the advancement of God’s Kingdom. Dr. Samaria maintains a zero-tolerance policy for events intended to exploit spiritual gifts for financial gain. If it is suspected that an event is being organized to facilitate the solicitation or manipulation of offerings, she reserves the right to decline or cancel the engagement immediately. *
Thank you for your interest. We will review your request and get back to you within 24 to 48 hours. Please note that Dr. Samaria is not confirmed as a speaker or participant for your event until you have received and  a confirmation of final booking. This document will be emailed to you once your request has been approved. *
Required
Due to Dr. Samaria’s clinical commitments and  schedule, we require a minimum of 30 days' notice for all speaking engagements. Please note that we are unable to accommodate last-minute requests. Furthermore, to honor her current schedule, Dr. Samaria does not participate in pre-consultation calls, event planning, or logistical meetings. We ask that all event details be finalized prior to booking, as Dr. Samaria’s role is strictly as a guest speaker and participant. *
Required
Your request will not be considered if you don't have the specific date (s), time and venue (location) of your event. *
Required
An honorarium is requested *
Required
NAME OF THE COMPANY/ORGANIZATION/MINISTRY
Name of Organizer *
THEME OF EVENT
Please be specific
Contact Person:  *
Phone number of the organizer, contact number, email address *
DATE OF THE EVENT *
MM
/
DD
/
YYYY
If your preferred date is unavailable, what are your secondary or backup dates? *
MM
/
DD
/
YYYY
The address of the event *
TIME OF EVENT *
Time
:
What is the allocated honorarium or budget for the speaker? *
Who are the other invited speakers? *
How many sessions are you requesting Dr. Samaria to speak at? *
What is the estimated number of attendees for this event? *
Speaker Provisions and Promotions: Dr. Samaria reserves the right to promote her books, products, and upcoming services/events during her presentation. Furthermore, as an invited speaker and guest, Dr. Samaria does not pay for vendor tables or exhibit space. A complimentary space for product display and sales must be provided by the host for any event she is requested to participate in. *
Is there an admission fee or registration cost for your event? If yes, please specify the amount. *
Travel and Hotel Accommodations Dr. Samaria is based in Greensboro, NC. For all out-of-town or overnight events, the host is responsible for arranging and paying for all travel and accommodations upfront. Please note that Dr. Samaria does not travel on a reimbursement basis; all bookings must be fully cleared and confirmed by the host in advance. *
HOW WOULD YOU LIKE DR. SAMARIA TO CONTRIBUTE TO YOUR EVENT? *
Required
"Is there any additional information or context you would like Dr. Samaria to consider? *
Official Communication Policy: To ensure all inquiries are handled efficiently and documented properly, please note that we do not conduct business via text message or social media platforms (including DMs and Facebook Messenger). All official business communication will be conducted exclusively through the business phone number and email address you have provided. *
Required
Dr. Samaria is deeply honored by every invitation she receives; however, she intentionally seeks prayerful alignment before committing to any engagement. Please understand that she does not accept every invitation and only attends where she feels led to serve. If she is unable to participate in your event, we ask that you do not take it personally, but rather as a reflection of her current focus and commitments. *
Required

To learn more about Dr. Samaria’s mission or explore our products and events, please visit www.drsamariacolbert.com.

Counseling Inquiries: This form is not for counseling requests. Please visit www.kingdomcreativecounseling.com for all clinical inquiries.

 To protect your privacy, we do not handle request changes via text, DM or social media. If you need to amend your request, please contact us directly via phone or email, or feel free to resubmit the form.

 *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Kingdom Creative Counseling PLLC.

Does this form look suspicious? Report

Google Forms