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Consultation Intake Form
Please fill out the questions below to help us learn more about how we can best support you.
First Name
Last Name
Email Address
Phone Number
Website Link
What are your top three goals or growth areas that you would like to focus on throughout our time together?
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Organization Description
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Speaking Engagement
Workshop & Training
Team Consultations
Black Healing Space
Organizational Culture Shift
Youth Corner
Leadership Coaching
Who and/or what department will the consultation(s) support? (frontline staff, clinical team, clients, management, etc.)
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How many people will be in attendance?
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What is your objective for the consultation(s)?
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What is your budget for the consultation(s)?
*
Please provide date(s), time(s) for the consultation(s) and/or committed time required for consultations.
*
Please specify the type of event.
*
Online Event (Zoom, Microsoft Teams, etc.)
In-person Event
Do you have an Anti-Racism strategic plan?
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Anti-Racism Specific Consultations. If you are requesting Anti-Racism specific consultations, please fill out the questions below.
Yes
No
N/A
Please describe your current Anti-Racism commitments and/or efforts.
*
How will this Anti-Racism consultation fit into your long-term organizational plans?
*
Do you require recordings? (Please note there will be additional fees to protect our intellectual property.)
*
Yes
No
Do you require handouts for participants? (Please note additional fees required)
*
Yes
No
Will any expenses be covered? (Food, Transportation, stay, etc.)
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Yes
No
Is there any additional information we should know?
*
How did you learn about us?
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Social Media
Website
Google
Referral
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Other
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