Healing as Resistance - Client Interest Intake From

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This form is to gather standard information from potential clients interested in DEIJ consulting, facilitation, and coaching services by Giovania Tiarachristie.

Company or Organization Name

Point of Contact Name

Point of Contact Email

Point of Contact Phone Number

Please briefly describe some of the challenges your company/organization is experiencing and why you are seeking these services:

What are some of your goals for seeking DEI and/or social justice facilitation services?

What kinds of services are you looking for?

One Half-Day Facilitated Discussion / Training

One Full-Day Facilitated Discussion / Training

A Series of Facilitated Discussions / Trainings

Executive & Leadership Coaching

Full DEIJ Organizational Assessment

Action Plan

Resource Kit

I'm not sure yet

Other:

Please select your top priority topics to cover:

Note: depending on the scope, it may not be possible to cover all of these topics, so please prioritize your top 1-2. Final topics will be determined after a deeper assessment of needs together with the client.

Diversity, Inclusion, Equity

Race, Racism, Racial Justice, Anti-Racism

Power, Privilege, Oppression

Unconscious Bias and Microaggressions

Identity and Intersectionality

Recruiting, Retaining, and Advancing Racial Diversity

Racial Equity in Planning and Policy

Other:

What is the size of the group of people you plan to engage in these activities?

<10 people

11-20 people

21-30 people

31-50 people

More than 50 people

Clear selection

Please describe to the best of your ability, the mix of demographics of your group in terms of race, gender, socioeconomic, professional background, organizational level, etc.

For example, "Majority white, senior-level professional planners, with less than a handful of people of color. 60/40 Male to female ratio."

Please let us know your understanding of the group's overall experience in engaging with racial equity and social justice topics:

Beginner (zero to little exposure to racial equity and social justice topics)

Intermediate (have had initial trainings or conversations, but want to go deeper)

Advanced (deeply engaged in action and conversations on racial equity and social justice)

They think they're liberal and progressive, but still problematic...

Not sure

When do you imagine these activities starting?

Please indicate at minimum the month and year, and if there are specific dates/weeks you are limited by

What is your company/organization's budget range for the services you seek?

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