Preliminary Information Form
Speech Coaching
              
  Name:
  Address:
 
State:
      Zip/Postal Code:
  Telephone:
  *E-mail:
     
Type of Coaching Desired (check one):  

   One-on-one
   Telephone  
   Email
   Video/DVD
  Area of Coaching Desired (check one): 

   Public Speaking  
   Voice  
   Performance

  
       
  (In 90 words or less)
What are your dreams and aspirations in the area you checked?
  
   
  (In 90 words or less)
What do you want to achieve with coaching in this area?  
  
   
  (In 90 words or less)
What are the major challenges you have in this area? 
       
 

How did you find out about Dr. Dilip’s coaching services? (Check all that apply below)
   Web surfing        
   Recommended by a friend 
   Chamber of Commerce listing
   Googling 
   Newspaper article about Dr. Dilip
   Heard Dr. Dilip speak
   Brochure
   Article by Dr. Dilip
   Toastmasters International

  

Once this form has been completed, 
print the form and
fax to: 717-728-2296
or mail to: P.O. Box 405, Enola, PA 17025

  
         
   Dr. Dilip R. Abayasekara
Mailing address: P.O. Box 405, Enola, PA 17025, USA
Fax Number: (717) 728-2296 Telephone: (717) 728-2203 Email: drdilip@centralpenn.edu