REQUEST SERVICES

Date *

MM

DD

YYYY

Contact: *

Name, Position

First Name

Last Name

Phone *

(###)

###

####

SERVICES:

Which services would you like to receive?

Professional Development & Training

Leader & Executive Coaching/Consulting

Signature Talks & Keynotes Request Services

Other

Does the organization have an intentional way to nurture accountability? Ex: internal Equity Team, DEI Committee, Employee Group(s), Affinity Groups, or a group holding the task of DEI related WORK? *

YES

NO

Has the organization/collective/company already budgeted for this work?

Yes

No

How would you to like services to be offered? (In-person or virtually) *

Virtually

In-person

Do you have preferred dates and times for your services? *

Yes

No