INTAKE FORM

Melanin & Medicine supports women health professionals of color who are interested in building new or funding existing healthcare service programs & enterprises that serve under-resourced communities. We are so excited to learn more about you and how we can support your vision to transform healthcare! Please take a few minutes to complete the form below with as much explanation as possible. Make sure to provide us with enough detail so we can provide you the best feedback possible.

First Name

Last Name

Email *

What is the URL of your personal Facebook profile OR your Instagram Handle? *

Cell Phone Number *

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

What stage is your for-profit or nonprofit business at currently? (Idea Stage, Growing/Building Stage, Some Clients/Revenue Stage, Established/Growing Stage)

Business Name

Business Website

What is your business mission (or idea)?

Tell me about the service you offer (or plan to offer).

What would success look like for you with your business?

What are your top 3 goals for your business in the next 90 days?

What are the top 3 challenges that you are facing right now?

Where do you need support to move forward your business (Choose all that apply)

Why is now the right time to work with Dr. Omolara and Team Melanin? What is the main reason you wanted to connect with us?

If this was referred by someone, who is it that we need to thank?

In order to best serve you, please do not submit this form if you are not interested in truly bringing this work to life. 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 transformative feedback.