LSA 7.28 Session Intake Survey
Thank you for taking a few minutes to help me get to know you! As part of my approach, I like to meet people where they are, and your input will help me to do so. Please feel free to reach out to me at
if you have any questions. Please know that your answers are confidential and will only be seen by me. I will not reference specific input or names during our workshop but may allude to themes I hear from the collective input. Thank you and I look forward to meeting you!
What is your name & role?
Where are you based?
Why did you choose to attend this workshop?
How do you identify racially?
Asian or Pacific Islander
Native American or Indigenous
What do you hope to get out of the workshop & why?
How would you describe the work you have already done around racism and whiteness?
I haven't done much, this is a starting place for me
I have done some (readings, workshops, talking to others, etc.) but I still consider myself newer to this
I have done a solid to strong amount of readings, workshops, etc.
My lived experience has taught me about racism and whiteness
Other (please explain below)
Please share more context about your answer above
What are your current fears (if any) about engaging in anti-racism? (e.g. being on the journey to be more racially aware and to be part of the solutions)
What else do you want me to know before our workshop?
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This form was created inside of Illuminate Coaching & Consulting.