NWS Wellness and Consulting, LLC Service Request Form (e.g., Consultation, Keynote presentations, etc.)

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Today's date *

YYYY

First Name, Last Name *

What is your Company/Organization? *

What is your Company/Organization size? *

What kind of service(s) are you interested in? *

Consulting

Keynote Presentation

Workshop/Training

Faith-based workshop/training

Media appearance

Would this service be... *

One-time offering

Multi-session offering

Retainer engagement: sustained service/support over time (3mo-12mo)

Unsure at this time

What topic would you like Dr. Natalie to address? *

Mindfulness in African Americans

Black Women's health and 'Strength'

Coping with stress

Self-care and stress management

Overcoming burnout

Faith-based mental health awareness

Antiracism for White allies

Other:

Tell us more about the aims of this service? *

When would this service take place? *

What is your budget? *

$500-$1,000

$1,000-$4,999

$5,000-$9,999

$10,000+

Unsure at this point

How did you learn about NWS Wellness and Consulting, LLC/Dr. Natalie? *

Anything else you would like NWS Wellness and Consulting, LLC/Dr. Natalie to know?

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