Organization Intake Form for Beadlieve in Change
Complete this form to help us understand your organization's needs and interests for scheduling a program.
Organization Information
Organization Name
*
Contact Person Name
*
First Name
Last Name
Role / Position
*
Please Select
Program Director
Coordinator
Case Manager
Teacher
Other
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City & State
*
Group Information
Who do you serve?
*
Please Select
Youth
Teens
Young Adults
Recovery Programs
Mixed Groups
Estimated number of participants
*
Please Select
5–10
10–15
15–20
20+
Describe your current programming
Program Interest
Services interested in
*
Please Select
Pilot Session (1-time)
Weekly Sessions
4-Week Program
12-Week Program
Not sure
Frequency preference
*
One-time
Once per week
Twice per week
Flexible
Creative activities of interest
Jewelry making
Vision boards / collaging
Journaling & writing
Painting / art
Mindfulness activities
Open to all
Scheduling
Preferred days
*
Monday
Tuesday
Wednesday
Thursday
Preferred time
*
Morning
Midday
Afternoon
After-school
Evening
Desired start timeframe
*
Please Select
ASAP
Within 2 weeks
Next month
Summer
Fall
Budget & Readiness
Have you budgeted for programming?
*
Yes
No
In progress
Budget range
*
Please Select
$150 (pilot session)
$1,200+ (4-week program)
$3,000+ (12-week program)
Open to discussion
How do you believe this program would benefit your participants and your organization? What specific outcomes or changes would you like to see as a result of this program?
Schedule a Call here!
*
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