Keynote CE Form

Keynote Speaker CE Form

Thank you for agreeing to present at the 2026 Fall Conference and Symposium, "TITLE TBD" taking place on [DATES HERE]. Information must be submitted by [DATE HERE]. The following information is required in order to fulfill requirements set forth by our co-sponsors.

Name(Required)

Please write your professional name, including post-nominal initials that represent your qualifications and credentials. The name submitted on this form will be listed as it is written in all conference related materials.

First Last Suffix

Email(Required)

Phone(Required)

Form W-9

Please upload a completed and signed Form W-9 so we can process your Honorarium and issue a 1099 if applicable. If you need the form, you can download it from the IRS website: https://www.irs.gov/forms-pubs/about-form-w-9 . Accepted file types: PDF (preferred), JPG, or PNG.

Max. file size: 20 MB.

Keynote Speaker Bio(Required)

Please provide a brief bio of no more than 150 words. This will be used in conference related materials.

Title of Friday Presentation(Required)

Friday Presentation Summary(Required)

Please provide a brief description of your presentation's central theme and content that does not exceed more than 300 words.

Title of Saturday Presentation(Required)

Saturday Presentation Summary(Required)

Please provide a brief description of your presentation's central theme and content that does not exceed more than 300 words.

Post-Test Question

Please provide two simple multiple choice question (with four possible answers) that address the main theme of each presentation. The correct answer must be included with each question. Questions provided by presenters will be used in a post-test to be included in the conference evaluation form given to PA social workers, LPC's and LMFT's who participate by watching the zoom recording, and who need CE credits for doing so. This is a requirement set forth by our co-sponsor.

[Friday Presentation] Please include the correct answer with your post-test question.(Required)

[Saturday Presentation] Please include the correct answer with your post-test question.(Required)

Presentation Details

Our CE Co-sponsor requires either a slideshow presentation, or a detailed outline, along with a bibliography listing at least 2 references from the last 5 years from each presenter. If you have a slideshow already completed, please upload your slideshow as a PDF. If you're still in the process of creating your presentation, please upload a 1-2 page thorough outline detailing its content.

[Friday Presentation] You must select one of the drop box items below:(Required)

[Friday Presentation] Upload either slideshow or outline consistent with above choice.(Required)

For easy reading of slideshows, please use bold print with a font size of 24 or greater.

Max. file size: 20 MB.

[Saturday Presentation] You must select one of the drop box items below:(Required)

[Saturday Presentation] Upload either slideshow or outline consistent with above choice.(Required)

For easy reading of slideshows, please use bold print with a font size of 24 or greater.

Max. file size: 20 MB.

Please upload a 1-2 page bibliography listing the most relevant references for both presentations. At least two references must be from within the last five years.(Required)

This is a requirement set forth by our co-sponsors.

Max. file size: 20 MB.

DONATE

Keynote Speaker CE Form

Post-Test Question

Presentation Details