Speaker Briefing

Speaker & Media: Insight To Action

Performance Powered By Resilience™

Thank you for your interest in engaging Bella Medical Associates for a speaking or media engagement. This brief intake is designed to help us understand your organization’s goals, audience, and context so we can determine the best-fit keynote, presentation, or workshop. Your responses allow us to prepare a focused, relevant discussion and ensure any potential engagement delivers clear value, practical takeaways, and meaningful impact—not generic inspiration.

Please note: completing this briefing does not represent a commitment. It supports an informed, strategic conversation about fit, outcomes, and next steps.*Indicates required fields.

Media-Only Requests

If you are reaching out for media, press, podcast, interview, or expert commentary (and not a live speaking engagement), please complete the section below. You may skip event-specific questions later in the form.

Type of Media Request (select all that apply):

Podcast interview

Panel or virtual discussion

Television or radio segment

Print or digital publication

Expert quote or commentary

Other (please specify)

Please specify if other:

Topic(s) or angles you'd like to explore:

(e.g., leadership resilience, burnout prevention, performance under pressure, workforce well-being, healthcare leadership, organizational stress)

Audience or Outlet (if applicable)

Preferred Timeline or Deadline:

(if applicable)

Contact Information & Type of Request

Organization or Outlet Name

Your Name

Your Role or Title

Best Email to Reach You

What are you reaching out about today?

Speaking engagement

Media request

Exploring options / not sure yet

What is the Budget range? (Optional, helps us tailor recommendations)

Event Information

Your Event Name

Target date or timing (if known)

Date speaker is requested

Preferred Time? (First Choice)

Preferred Time? (Second Choice)

Is there more than one appearance requested?

Yes No

Date of Appearance #1

Date of Appearance #2

Any additional information about Speaker Request Date & Time?

Location or virtual format

Online In Person

If In Person: Provide City, State, Zip Code, Venue

Preferred length (approximate)

Event/Organization Hashtag?

What prompted this request?

Primary theme or focus area

What exactly would you like Bella Medical Associates to complete (i.e. – Keynote, Speaker, Conference, Workshop, Retreat, Private health seminar)?

What would make this engagement successful for you?

What is the greatest challenge your attendees are facing?

Confirm the time for Bella Medical Associates AV/sound check.

How are you envisioning the format?

Keynote

Workshop

Panel / discussion

Interview

Not sure yet

Event Attendees and Outcomes

Approximate audience size (if known)

What would you like your audience to do differently as a result of Bella Medical Associates presentation?

What are you hoping to get out of the event/meeting?

What speakers have you had in the past who were a hit? What made that experience successful? Have there been any who did not go over well (and if so-- what happened)?

Describe your attendees:

Approximate audience size (if known)

a. Age range (if known)

b. Percent of Males (if known)

c. Percent of Females (if known)

Describe your attendees' professional level

If etc., please explain

Audience or outlet (if applicable)

Will spouses be attending the event?

Yes No

What is the greatest challenge your attendees are facing which you would like addressed?

Are there any industry issues or challenges Bella Medical Associates needs to be aware of?

What is of most importance to your attendee experience? (Check all that apply)

Motivation

Customized Content

Depth of Content

An out of their SEAT activity

If event is for your employees or team, what do they do well?

If Women's Issues, Explain

If Men's Issues, Explain

Point of Contact

Your First Name

Your Last Name

Contact’s Name and Title

Contact’s Email

Contact’s Address/City/State/Zip

What is your role with planning the event/meeting?

Name for texting?

Cell Phone number for texting

Who is Speaker’s contact at the event?

Language:

What does your organization call your "upline" Leaders? Boss? Managers? Supervisors? Team Leaders? Project Leaders? Something else? (Bella Medical Associates wants to include or use YOUR language)

What does your organization call your Internal Customers- Team? Co-workers? Projects? Group? Department? Cross-Functional Team? (Bella Medical Associates wants to include or use YOUR language)

What does your organization call your End User- Patient? Customer? Client? Consumer? (Bella Medical Associates wants to include or use YOUR language)

For Events Outside of Albemarle, NC and Charlotte, NC:

Is travel and lodging included for the speaker PLUS one assistant?

Yes No

If Yes:

a. What is the name and where is the closest airport?

b. Will ground transportation and meals be provided?

Budget range (optional, helps us tailor recommendations)

How did you hear about our services?

Anything else you’d like us to know?

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