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PurpLE Health Speaker and Training Request Form
Thank you for your interest in collaborating with our team! We use the information provided to tailor presentation content and provide an estimated cost for the session. All fees and honorariums go towards supporting our non-profit's mission, including facilitating free healthcare for GBV survivors and their children. We are sensitive to the budgetary constraints of non-profit and student events and can find ways to collaborate accordingly. Thanks again, and please feel free to let us know if you have any questions: Training@PurpLEHealthFoundation.org
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Name
*
Your answer
Email
*
Your answer
Organization Name
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Your answer
What service are you requesting?
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Training - Single Event
Training - Longitudinal Engagement (Trainings/workshop series)
Speaker
Required
PurpLE Health expert you are seeking for event
Any PurpLE Health staff member
Anita Ravi, MD, MPH, MSHP - PurpLE Health CEO, Co-Founder, Physician
Keisha Walcott - Survivor Leader, Care Navigator, Founding Board Member
Jessica Gorelick, LCSW-R, MA - Director of Mental Health and Social Work, Co-Founder
Other:
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How did you hear about PurpLE Health?
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Previous Conference or Training
Professional Network
Internet Search
Linked In
Twitter
Facebook
Instagram
Other:
Required
Conference Title (if applicable)
Your answer
Format
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In-person
Virtual
Other:
Topic
*
Your answer
Presentation Date and Time
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Your answer
Presentation Length
*
Your answer
Will there be required preparation or planning meetings? If so, please provide details on the frequency and length of meetings.
*
Your answer
Will presentation be recorded?
(Please note, we typically opt out of recordings of trainings and workshops, but are happy to review requests on a case by case basis)
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No
Yes
Other:
Anticipated Number of Attendees
*
Your answer
Background(s) of Attendees (Ex: Physicians, NPs, Social Workers, Survivor Community Members, Residents, Students, Lawyers, Patient Advocates, etc.)
*
Your answer
Honorarium Amount
*All honorariums go towards supporting our non-profit's mission, including facilitating free healthcare for GBV survivors and their children.
*
Your answer
Any additional information to convey to our team
Your answer
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