Client Form DEIBA Consultation Services Form
Client Details:
Person of Contact Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Organization Name
*
Organization Website
*
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Service(s) requested:
*
Assessments
Consulting
Facilitations
Facilitations Virtual
Single deliverables
Research (Quantitative)
Research (Qualitative)
Keynote or plenary presentations
Please provide the approximate number of event participants(required)
*
The location of the event if in-person
*
City, State, Space/Location
Do you require Zoom Platform Use if virtual event
*
Yes
No
Not Sure
Are you a non-profit organization/501c3 or a small business?
*
Yes
No
Do you already have an approved budget?
*
Are you the main point of contact that we'll be working with on a day-to-day basis?
Yes
No
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
What are you interested in knowing more about for your organization? (Check all that apply)
Discrimination & Sexual Harassment
Diversity Action Planning
Facilitation & Workshops
Keynote Speaking
Diversity Audits & Reviews
Assessments & Surveys
Consultant Retainer Service
Strategic Diversity Planning
Lunch & Learn Series
ADA Compliance & Accessibility
Board Member Training
Establishing Employee Resource Groups (ERG)
If you are seeking DEIBA Consulting Assessment Services for your business, do you have a strategic plan?
Yes
No
In progress
If yes, is the strategic plan consistently reviewed,utilized, and updated?
Yes
No
Anything else you'd like us to know?
Submit
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