Booking Request Please complete the form below to reach out about our services. Organization and Contact InformationName(Required) First Last Profession(Required)Make a selection...Arts EducationAttorneyAfter-School CoordinatorCase ManagerClergyCounselor - GeneralCounselor - Child/AdolescentCounselor - Community/Mental HealthCounselor - School K-12HR ProfessionalLaw EnforcementMarriage & Family TherapistNurse - GeneralNurse - Behavioral HealthNurse - EducationNon-Profit Executive DirectorNon-Profit AdministratorOffice ManagerOther - Behavioral HealthPersonal Development CoachPhysicianPsychologistPsychologist - Child/AdolescentPsychologist - School K-12Social Worker - GeneralSocial Worker - Child/AdolescentSocial Worker - Community/Mental HealthTeacher - High SchoolTeacher - Middle SchoolTeacher - Elementary & Pre SchoolTeacher - College/UniversityTeacher - Special EducationYouth DevelopmentOther (enter below)If you select Other or require additional space, please use the Profession Description field below.Title/PositionAdditional Profession DescriptionOrganization Name(Required)Enter "Individual" if request is not affiliated with an organization.Contact PhoneEmail(Required) Enter Email Confirm Email Organization Main Phone NumberOrganization Website Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I am interested in booking Flourish Agenda for:(Required) Four Pivots Learning Journey Healing Center Engagement Online Certification* Keynote Presentation Customized Training or Workshop Camp Akili Youth Camp Organizational Coaching or Consulting Four Pivots Learning Journey Options*Four Pivots Learning Journey is a non-clinical, strengths-based approach that advances a holistic view of healing and re-centers culture and identity as a central feature in personal well-being. This course will help youth development professionals explore ways they can enhance their practices and policies to more effectively reach and impact youth of color. Which option are you interested in?(Required) Take this Journey as an Individual Take this Journey as a Cohort (20 to 40 people) When would you like to start? MM slash DD slash YYYY HCE Course Options*Healing Centered Engagement (HCE) is a non-clinical, strengths-based approach that advances a holistic view of healing and re-centers culture and identity as a central feature in personal well-being. This course will help youth development professionals explore ways they can enhance their practices and policies to more effectively reach and impact youth of color. When would you like to start? MM slash DD slash YYYY Which option are you interested in?(Required) Take this Certification as an Individual Take this Certification as a Cohort (20 to 40 people) This field is hidden when viewing the formIn which month(s) would you ideally like to begin the course?No preferenceJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDo you already have a Cohort that will take the course?(Required) Yes No Will you be part fo the Cohort taking the course?(Required) Yes No I do not know yet. How many people do you estimate will be in the Cohort?(Required)Event InformationPlease provide a detailed description or scope for your project or event (include demographics of recipients of participants, number of stakeholders/providers, etc.)Is this request for a scheduled event?(Required) Yes No Event Date(Required) MM slash DD slash YYYY Event Location(Required) Same as Organization Other Location Virtual Event NameName of Event LocationThis field is hidden when viewing the formEvent Location Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is the time frame or when would you prefer this to occur?(Required)Is this time free flexible?(Required) Yes No Estimated Number of AttendeesBudget Range for Request(Required)This field is hidden when viewing the formHow flexible is this time frame?Please share any additional details you think would be helpful to review your request including the name and contact email for the contract signatory.What is the goal, or what problem are you trying to address?(Required)What are the outcomes that you want to see? What does success look like?(Required)How did you hear about Flourish Agenda? Recommendation from a friend or colleague X/Twitter Facebook Instagram LinkedIn Medium Podcast Search engine (Google, Yahoo, etc) Employer Event (webinar, keynote speech, training) (Please indicate what event or year and date) Other Please indicate the name or organization presenting the event (webinar, keynote speech, training) and when:If you heard about Flourish Agenda & HCE Certification through another source, please use this space to describe:ConsentBy submitting this form, you agree to be added to our mailing list. To opt-out of marketing and other communication not related to this specific submission, please indicate that request below by selecting the Opt-Out option. Do not add me to your mailing list. Submit EmailThis field is for validation purposes and should be left unchanged.