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Booking Request

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Organization and Contact Information

Name(Required)

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Profession(Required)

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Organization Name(Required)

Enter "Individual" if request is not affiliated with an organization.

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Address(Required)

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I am interested in booking Flourish Agenda for:(Required)

Healing Center Engagement Online Certification*

Keynote Presentation

Customized Training or Workshop

Camp Akili Youth Camp

Organizational Coaching or Consulting

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.

Which option are you interested in?(Required)

Take this Certification as an Individual

Take this Certification as a Cohort (20 to 40 people)

When would you like to start?

MM slash DD slash YYYY

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In which month(s) would you ideally like to begin the course?

Do 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 Information

Please 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 Name

Name of Event Location

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Event Location

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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 Attendees

Budget Range for Request(Required)

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How 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

Twitter

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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:

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