First Name

Last Name

Phone

What is your title/role at your organization?

Organization/School Name (no abbreviations)

ex: University of California, Los Angeles (not UCLA)

Organization/School Street Address

Organization/School City

Organization/School State/Province

Organization/School Zip Code

Enter "other" State/Province here:

Event Planning Information

What is your 1st preferred date for your event?

What is your 2nd preferred date?

Preferred time of presentation?

Have you previously hosted an Active Minds Speaker?

Previously Hosted Speaker

Does your organization require the use of its own performance agreement/contract?

Billing Contact First Name

Billing Contact Last Name

Billing Contact Title/Role

Billing Contact Email Address

College students	Community members
Faculty/Staff (educators)	Healthcare Workers
Managers/Employees	Parents/Caregivers
Professionals	Students (high school)
Students (K-8)	Veterans/Active duty service members
Other

Anxiety/Panic Disorder	Asian American Mental Health	Athletes	Black, Indigenous, People of Color Mental Health	Bipolar Disorder
Bullying	Depression	Domestic Violence	Eating Disorders	Fraternities/Sororities
K-12 Audience	Latinx Mental Health	LGBTQ+ Mental Health	Life Transitions	Men and Mental Health
Mental Health and Current Events	Mental Health and the Pandemic	Mental Health Awareness	Mental Health in the Workplace	Mindfulness
Music/Creativity and Mental Health	Obsessive Compulsive Disorder	Perfectionism	Personality Disorders	Post-Traumatic Stress Disorder
Religious/Spiritual Communities	Resilience	Self-Care/Self-Compassion	Self-Injury	Sexual Assault/Rape Culture
Stigma Reduction	Stress Management	Substance Use and Abuse	Suicide Prevention	Trauma
Veterans/Active duty service members	Women and Mental Health	Other