Pre-Program Questionnaire

This information will help Mona Barbera give you the presentation you need. We will go over this on the phone, or if you prefer, fill in as much of this as you know and email it to Mona.

First Name:
Last Name:
Company / Association Name:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Area Code: Phone:
Fax:
Email Address:
Web Site:
Meeting Date:
Length of Talk/Workshop:

---------------------------------------------------------------------------------

The Program

What is your program theme?

What is the name and title of Mona Barbera's introducer?

Time for Mona Barbera's presentation(s)?

Time for Mona Barbera to do her a/v and room check?

What will participants be wearing? How do you want Dr. Barbera to dress?

What Dr. Barbera's role in the program? (opening or closing keynote, luncheon speaker, workshop leader, break out group.)

Who will be speaking before Dr. Barbera? On what topic(s)?

Who are the other professional speakers on this program?
Speaker #1:
Topic:
Day:
Speaker #2:
Topic:
Day:
Speaker #3:
Topic:
Day:

What professional speakers have you used in the past?

What did you like about their performance?

---------------------------------------------------------------------------------

Logistical Information

What is the nearest major airport to the meeting site?

What are the options for transportation to and from the airport?

Address of the meeting and additional description (where to go upon entering campus, main entrance, etc.):

Will a video crew be on site?
Company:
Contact:
Phone:
Email:

Would you be interested in purchasing "Bring Yourself to Love: How Couples Can Turn Disconnection into Intimacy" for the attendees (bulk purchase discounts available)?

May Dr. Barbera have her book for sale in the back of the room?

---------------------------------------------------------------------------------

Audience Analysis

Exepcted number of attendees:
Percentage male:
Percentage female:

Are there important changes happening in your group?

What would you like to accomplish by Dr. Mona speaking for your group?

What does Dr. Mona need to do to make her talk worthwhile to you?

What slogan or philosophy does your group use?

What do audience members do on a day-to-day basis? (therapists seeing clients, work in various occupations, administration, students, etc.)

Any group jargon, jokes, or recent humorous or sad events Dr. Mona should be aware of?

In case of emergency or flight delays who do we call and at what phone number (please include a cell phone if that will make it easier to reach you)?

Three people valuable for Dr. Mona to interview to get background information useful for adapting her talk to your group:

1. Name and title:
Phone:
Email:

2. Name and title:
Phone:
Email:

3. Name and title:
Phone:
Email:

As soon as they are available please send:

A. The agenda, brochure, or announcement of the meeting.

B. Past conference/meeting brochures.

Create a link to Dr. Mona's website so attendees can get more information:
http:// www.monabarbera.com

Room preferences: Dr. Mona prefers that the audience be a bit cramped rather than a tiny speck in a huge room, that she have a riser so she can be seen, and that the audience is close to the speaker.