Discovery Form

Thanks so much for connecting with us! We want to learn about where you are in your journey towards social entrepreneurship. We provide support at all stages -from refining your idea into a business plan, providing comprehensive business development coursework with high-touch coaching, business growth strategy & services to help you secure 6-figure external funding without loans! Our services are all provided with integrated mindset support within a priceless community of women of color committed to health justice. Please complete the form below and we will connect with you for more details as needed. Please be as detailed as possible so we can have a very clear understanding of your exact needs and goals.

First Name *

Last Name

Email *

What is the URL of your preferred social media channel (Facebook, Twitter, Instagram or LinkedIn) *

Have you Filed Your business as an Entity? If so, what is the official filed name of your business/non-profit? *

Cell Phone Number *

Do you consent to receive text messages from Melanin & Medicine?

What is your specialty in medicine? *

How many years out of training are you at this time? *

What areas are you interested in getting support for at this current time? *

Can you share in detail the scope of the problem and what exactly you want to improve? *

Please share the goals you would like to accomplish in the next 12 months and what you feel would make the biggest difference in the next 90 days *

What are the top 3 challenges that you are facing on the path to achieve your goals? *

Are there any mindsets or fears that are keeping your from your desired goals? *

Why is now the right time to connect with our company? What is the main reason you reached out to get support from us to build your vision? *

At this point, Is there anything that would stop you from investing in yourself and getting support to achieve your goals? if so, please share the details below *

How soon are you looking to get help? If we can identify a service that's a good fit, how ready are you to enroll in a program or course that will support you to reach your vision? *

I'm ready to go now!

Looking for support in 3-6 months

Looking for support in the next 6-12 months

I'm not sure, looking into several options

If you are filling out this form after discovering our coaching services, which program were you interested in learning more about?

Lastly, how did you get connected to fill out this form?

If you were referred by someone, who is this amazing person that we need to send a thank you to?

In order to best serve you, please do not submit this form if you are not interested in taking action. We take these support inquiries very seriously and are committed to spending time and energy to identify what resources may be right for you. At times, this may even result in a referral to one of our preferred partner services for support. If you are an action taker, ready to invest in yourself and understand the impact of pouring into yourself as the best way to help others, please submit your request!

Keep in mind that the more detailed your answers, the more likely we are to provide you with the right resource to fit your needs!