Speaker Request Form
Speaker Request Form: Please check the box indicating that you have read and understood the following statements. DO NOT USE THIS FORM TO REQUEST A THERAPY SESSION YOUR REQUEST WILL NOT BE RESPONDED TO. To schedule a therapy session visit the website: www.kingdomcreativecounseling.com
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Email *
Dr. Samaria is a dynamic speaker, author, entrepreneur and trainer. She welcomes the opportunity to pour into the lives of others. Please complete the following information regarding your request to have Dr. Samaria speak. For any other business inquiries still, complete the form as well. Let's make a kingdom connection.
Disclaimer: For those of faith communities. Please be aware although Dr. Samaria does request an honorarium she does not speak, or use her spiritual gifts for the specific purpose of soliciting money from people. All of her gifts are specifically used to aide in the healing of people and advancing God's kingdom. They are not used to manipulate people to give an offering. If Dr. Samaria suspects that she is being booked for this reason, she reserves the right to cancel or decline the requested event.  *
I understand that upon completing the form, we will get back to you within 24 to 48 hours in regards to your event. Dr. Samaria is not confirmed as a speaker (or participant of any kind) at your event until the contract is signed. Contracts will be emailed to you if your request is approved *
Required
Due to Dr. Samaria's schedule with her therapy client's we ask that you give us at least 30 days notice prior to your event. Last minute request will be declined. Thank you. Please note for ALL requests Dr. Samaria does not do pre-consultation calls or meetings for events she is requested to speak at. Meaning Dr. Samaria does not assist in preplanning or helping you plan your event. *
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 *
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What are the alternative dates for your event? *
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The address of the event *
TIME OF EVENT *
Time
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WHAT IS YOUR SPEAKER BUDGET? *
Who are the other invited speakers? *
How many sessions are you requesting Dr. Samaria to speak at? *
 WILL DR. SAMARIA BE ALLOWED TO PROMOTE HER PRODUCTS, BOOKS, FUTURE EVENTS AND SERVICES? PLEASE BE AWARE THAT DR. SAMARIA DOES NOT PAY FOR VENDOR TABLES TO EVENTS SHE IS A REQUESTED PARTICIPANT AT. *
IS THERE A CHARGE FOR YOUR EVENT? IF SO HOW MUCH? *
WILL TRAVEL/HOTEL ACCOMMODATIONS BE OFFERED? PLEASE BE AWARE THAT DR. SAMARIA IS IN GREENSBORO NC FOR ALL LONG DISTANCE, OUT OF TOWN AND OVERNIGHT EVENTS ACCOMMODATIONS (INCLUDING TRAVEL REIMBURSEMENT) ARE REQUIRED *
HOW WOULD YOU LIKE DR. SAMARIA TO CONTRIBUTE TO YOUR EVENT? *
Required
ANY ADDITIONAL INFORMATION YOU WOULD LIKE FOR DR. SAMARIA TO KNOW OR CONSIDER? *
Please be aware we do not communicate any business related matters over text message, DM, FB messenger or social media. We will communicate directly via the business phone number and email you provided us. *
Required
For more information about Dr. Samaria's mission and to view other products, events and services visit the website at www.drsamariacolbert.com. Please do not use this form for counseling inquiries go to Kingdom Creative Counseling PLLC by visiting the website www.kingdomcreativecounseling.com Any changes that you need to make,  we will not communicate via text message, dm or social media. If changes are made contact us via the phone or email, we will amend your request as needed or you may resubmit your request *
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