LTB Consultation Interest Form
Thank you so much for your interest in working with Liberate The Block (LTB)! Please fill out the information below. Once completed, our team will look it over and get back to you about if this is a good fit and any related service fees associated with the project.
Email *
First & Last Name & Organization *
How Did You Hear About Our Services? *
Which best describes you? *
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Which best describes the audience you are requesting services for? *
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Below are a list of topics we provide Consultation, Workshops/Support Groups, Needs Assessments, & Program Development and Evaluation services on. Please select all that apply to what you are seeking help with today. *
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What specifically are you hoping to gain from our services? Please list at least 1-3 goals/objectives. This includes your vision for how our services will help transform your organization. This helps facilitate an efficient and effective consultation process. *
What motivated this request? This can include specific issues/barriers that have arisen, wanting to be preventative, and/or maintaining/enhancing progress already made.  *
When would you like to schedule your consultation/speaking engagement? Please answer to the best of your ability (e.g., month, year, days of week & times that are best for you, estimated timeline). *
Preferred method of interaction. *
If requesting in-person services, will transportation to and from the event be covered? *
Which service(s) are you interested in? We offer a variety of options, including Consultation/Speaking Engagements (30 minutes minimum to full year projects/series); Workshops(one time to full series); Support & Affinity Groups (one time to full series); & Program Development, Evaluation, & Needs Assessments (one time to full series). Please select all that apply.  *
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How many sessions are you seeking? *
Is Your Organization Interested In Any Additional Offerings With This Request? *
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If you organization is offering an honorarium/travel & lodging, please place the value and other specifics below. Please put N/A if not applicable.  *
Please list any other information that would be important for us to know.
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