CLIENT INTAKE FORM

Name *

First

Last

Email *

Phone number:

Title/Position:

Organization/Affiliation:

Are you requesting services for yourself or on behalf of the above organization? *

Self
Organization

Age:

Gender:

Racial/ethnic identity:

What is your highest level of education?

Consultation interest: *

1-on-1 Sessions
Project Collaboration
Speaking Engagements
Organizational Climate Assessment and Intervention

Please specify:

For 1-on-1 sessions, on a scale of 0 to 5 how important is it to focus on faith/spirituality during your session(s)? (0 = not important at all, 5 = extremely important)

Selected Value: 0

List 3 of your/your organization's greatest strengths: *

List 3 areas that you/your organization would like to improve: *

What are you hoping to gain from Dr. Bridgette's executive consulting services?

Complete the following sentence: "If consultation with Dr. Bridgette is successful, I/my organization will…"

Is there anything else you would like us to know about you/your organization to help tailor the services? (e.g., main challenges you are facing, event target audience and size [for speaking engagements])

If you choose to become a client, how will you pay for consulting services?

Personal funds (out of pocket)
Personal funds within my organization (e.g., start-up, discretionary account)
Organization’s funds (e.g., school or department funds, corporate account)
Uncertain at this time

How did you hear about this consulting service?

CLIENT INTAKE FORM

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