Book NCC

Thank you for considering Neisha Christine Consulting for your next event! For public speaking engagements and/or workshop facilitation, please complete the below form. For individual or corporate consultations, please email neishachristineconsulting@gmail.com to schedule an introductory appointment.

Event Overview

Event Title *

Name of Agency Hosting Event *

Contact Person *

Title *

Phone # *

Email Address *

Event Date *

Event Start Time *

Event End Time *

Requested Arrival Time

Will the event take place rain or shine? *YesNo

If “no”, please provide rain date

Event Address *

City

State/Province

ZIP / Postal Code

Brief Description/Purpose of Event *

Dress Code *

Venue Description/Layout (e.g., auditorium, conference room, stage, ballroom, outdoors, etc.) *

How did you hear about Neisha Christine Consulting? *Social MediaSearch Engine (Google, Yahoo, etc.)Word of Mouth (Friend, Family, Colleague, etc.)Attended a Workshop/EventOther

If “other”, please explain

Target Audience

(Check all that apply) *Domestic Violence SurvivorsAdvocates/CaseworkersChildren/StudentsAdults 18-54 years oldSenior Adults 55+Parents/GuardiansSchool Staff/AdministrationFaith-Based CommunityPublic Health/Medical ProfessionalsAttorneys/Legal StaffMilitary/Law EnforcementLegislators/Elected OfficialsGeneral PublicOther

If "other", please explain

# of People Expected to Attend *

Expected Media Coverage? *YesNo

Presentation Topic

(Check all that apply) *Personal Survivor Testimonial: My JourneyDomestic Violence/Intimate Partner Violence 101Topic Specific Deep-Dive (Financial Abuse, Teen Dating Violence, etc.)Domestic Violence & Marginalized Communities (BIPOC, LGBTQ+, Men, etc.)Building Healthy RelationshipsNavigating Legal & Social SystemsBystander Intervention & Community SupportCreating Safe WorkplacesPracticing Trauma-Informed CareLife After: Pathways to Healing for SurvivorsMotivational/Overcoming AdversityWomen In Business/Leadership EmpowermentOther

If “other”, please explain

Type of Presentation

(Check all that apply) *Keynote SpeakerPlenary SpeakerSpoken WordWorkshop FacilitatorPanelistVirtual/WebinarModeratorEmcee/HostAwareness TableOther

If “other”, please explain

Length of Presentation *

Q&A to follow? *YesNo

Equipment Provided

(Check all that apply) *Microphone (Handheld, Lapel, Podium)Audio/VisualLaptopTableTableclothChairsElectrical OutletExtension CordNoneOther

If “other”, please explain

If you selected table, or chairs, or both, please provide the length of the table and the number of chairs

Agency Representative Acknowledgment

* By electronically signing this form, I certify the above information to be true and correct. Furthermore, I acknowledge my submission of this form does not constitute a contractual agreement between myself and Neisha Christine Consulting, LLC, and that the information I have provided is pending further review and approval.

Signature *

Date *

Contact NCC