Intake Form

Thanks so much for connecting with us! It is our mission to provide a one-stop shop for community and coaching for Black women in healthcare to help them thrive. Our support includes personal development, work-life integration, career planning & transition or even pivoting into entrepreneurship. Please complete our intake, so we can learn more about you. Please be as detailed as possible so we can have a very clear understanding of your exact needs and goals, so we can provide you with personalized feedback about if and how we can support you.

First Name *

Last Name

Email *

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

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? *

Why are you interested in getting support 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

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?

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!