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Thank you for considering Jackie as a speaker for your event. Please complete this questionnaire to let her know about your group and the event you are planning.

The more information you provide, the better Jackie can determine the best way to meet your specific needs and customize her presentation. Please fill out the form as completely as possible and be sure to ask any questions you need answered in the last box on the form. Thank you for your time and information.

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Title(s) of Presentation(s) Requested:

Creating Connections

A Life of Gratitude
Conversation Awareness
Intuition & Leadership
Your Body Talks & the World Listens
Motivating, Heathy Workplace Community
Extreme Career Makeover with Patience
Create Balance
Live for Today!
Team/Trust Building
Your Health/Life
Other Customized Topic

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Who is the audience?
What is the theme and purpose of your event?
What are the specific objectives for the presentation?
Are there any sensitive issues that should be avoided?
What are three main things that should be known about your group before addressing them?
What significant events have occurred in your organization or group in the past year?
What takes place immediately before, during and after this presentation?
Please list below the names and titles of people in your organization with whom we should be familiar:
Questions? Comments? Additional Information?
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Jackie Bredl-Dietrich, CHES, PCC
Life & Business Coach, Speaker, Consultant & Author
P.O. Box 1101, Wisconsin Rapids, WI 54495



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