Dr. Chervinsky Speaker Request Please make event request at least four weeks prior to event. Name * First Name Last Name Organization * Email * Name of event (please add brief description) Topics for presentation Event Date * MM DD YYYY Length of Speaking Time * Virtual or In-Person * Virtual In-Person Venue name Venue Address Address 1 Address 2 City State/Province Zip/Postal Code Country Public or Private * Public Private Budget range * Does honorarium include travel/accommodation? * yes no Will books be sold? * yes no How did you find Dr. Chervinsky? * Google or search previous event referral podcast or interview opinion piece or news article other