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Contact Information
Church, Organization or Business Name*
Primary Contact Name*
First Last
Title
Phone*
Email*
Your role in organization*
- Pastor
- Staff
- Elder/lay leadership
- Community leader
- Non-profit director
- Business leader
- Board member
- Shareholder
- Other
Type of Presentation
Service Requested*
- Speaking engagement
- Workshop facilitation
- Consulting service
- Demographic Tour
- Other
Date
Date Format: MM slash DD slash YYYY
Time

: HH

MM
Location
Street Address Address Line 2 City State ZIP Code
Please let me know...
How did you hear about Susan Nichols & Community Connections Consulting?
What would you say is your biggest need in your organization?

Fees are based on the specific service request and will be discussed in the initial consultation after the Service Request Form is received.

Contact Me

susan.nichols@yahoo.com
281-782-5818

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