Social Impact Practice Funding Readiness Intake

Melanin & Medicine supports women health professionals of color who are interested in funding their service-based healthcare companies that serve under-resourced communities. We are so excited to learn more about your vision to transform healthcare and help you think through next steps to get it funded! Please take a few minutes to complete the form below 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 healthcare practice at currently? (Idea Stage, Growing/Building Stage, Some Clients/Revenue Stage, Established/Growing Stage) *

Business Name *

Business Website *

State *

What county in your state is (or will) your business operate in? *

What is the social, mental or physical health problem that your business is tackling within your company? *

Tell me about the target population, you want to serve- how are they under-resourced or experiencing gaps in care now? *

Tell me about the direct services you offer (or plan to offer) and why it would be better than what exists for your target community?? *

Have you had any previous experience tackling this problem or providing these services in the past?

What is the average monthly revenue for your company in the last 3 months only? *

What are the top 3 goals you want to accomplish for your business over the next 6 months? *

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) *

If you were able to get $100k in funding in the next 6 months, do you know how you would use it to either build or grow your company?

Keep in mind that the more detailed your answers, the more likely we are to provide you with more robust, personalized video feedback!