Initial Alignment Intake Form
This brief intake helps us determine foundational fit before scheduling a conversation. It is not a commitment — simply a clarity step.
Organization / Institution Name
Primary Contact Name & Role
Email Address
example@example.com
Country / Region
Area of Interest (Select all that apply)
Healthcare / Medical
Penal / Justice System
Education
Leadership / Professional Development
Other (please specify)
What prompted your interest at this time?
What challenge are you hoping to address? (Check the most relevant)
Staff burnout / fatigue
High stress or reactivity
Emotional escalation or conflict
Capacity, focus, or decision-making under pressure
Preventative health and well-being
Other
Which best describes what you’re exploring?
Introductory training
Organizational program
Train-the-trainer / certification
Not sure yet
Timeline
Immediate (0–3 months)
Near-term (3–6 months)
Exploratory / future planning
Anything else you feel is important for us to know?
Thank you. If there appears to be alignment, we will follow up with next steps.
Submit
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