Speaker Request Form Contact Information: Name (required) Email (required) Phone Number Organization Name Organization Location Please briefly describe your organization. What prompted you to seek a speaker on LGBTQIA+ health? Event Information: Event/Panel Title Event/Panel Date Event/Panel Location Is the date/time of the event/panel flexible? If yes, how so? Are you open to a virtual speaker? If not, are you able to pay for travel costs? YesNo Do you have funding that you are able to put toward an honorarium? YesPotentiallyNo Please indicate budget Please explain Who is the intended audience? CliniciansFront-line staffSpecialty providersAll-staffPatients/FamiliesClientsLeadership/Executive staffOther Other (please specify) What is the size of the audience? Is there a particular topic you would like the speaker to address? (CTRL+Click to select multiple topics) LGBTQIA+ Terms/DefinitionsCreating Inclusive and Affirming Environments for LGBTQIA+ (or specifically Transgender and Gender Diverse) PatientsLGBTQIA+ (or specifically Transgender and Gender Diverse) Care: Stigma, Disparities and TerminologyImplicit Bias in Care for LGBTQIA+ (or specifically Transgender and Gender Diverse) PatientsPrimary and Preventive Care for LGBTQIA+ (or specifically Transgender and Gender Diverse) PatientsMental Health Care for LGBTQIA+ (or specifically Transgender and Gender Diverse) PeopleEffective and Affirming CommunicationSexual Orientation/Gender Identity (SOGI) Data CollectionLGBTQIA+ Older AdultsLGBTQIA+ YouthOther Other (please specify) Do you have an existing educational program? YesNo Is there anything else we should know about your request?
