REQUEST SERVICES

We appreciate your interest in receiving services. Please compete this short client services survey so we can follow up with you and get things started.

If you’re sure you there’s interested in receiving services from THE HUMAN ROOT please complete the client survey. We will contact you and set up a call to get things started!

Request Services

Date

YYYY

Name of Organization/Collective/Company:

Contact:

Name, Position

First Name

Last Name

Phone

(###)

###

####

Address of Organization/Collective/Company

Organization/Collective/Company Size

• # of members/staff: • # of Board Members: • # of Humans you serve: • Avg. Budget Annually: $

Team members responsible for retaining services for your org/institution (if applicable):

name(s), position/role

CONSULTATION / SERVICES DETAILS

Does the organization have an intentional way to nurture accountability? Ex: internal Equity Team, DEI Committee, Employee Group(s), Affinity Groups, or a group holding the task of EDI related WORK?

YES

If yes, please tell us how and about the group(s) or committee(s)

Has the organization/collective/company already budgeted for this work?

Yes

How would you to like services to be offered? (In-person or virtually)

Virtually

In-person

Where will services be held?

Where will your team/staff/community be located during services?

Please describe any pre-discussed or agreed upon needs and ideas for structure of consultations or trainings?

Do you have preferred dates and times for your services?

Yes

If yes, list them here:

When are you available to schedule and informational call? Please list 3 dates and times:

Your introductory information call will be 30min

If you would like to set up a call or contact us for more information please respond to the short form below.

GENERAL INFORMATION

Email: info@thehumanroot.com
Call (347)994-5094

Name

First Name

Last Name

Phone

(###)

###

####

SUBJECT:

Message