Let’s Connect! Interested in working together or learning more? Fill out the form and we will be in touch shortly! INTAKE FORM Name * First Name Last Name Email * Phone * Country (###) ### #### Role / Job Title / Occupation * Preferred Method of Contact * Email Phone Call Phone Text All ORGANIZATION INFORMATION (if applicable) Organization / Company Name Industry Number of Employees 1 - 10 11 - 50 51 - 200 201 - 500 500+ Website http:// SERVICES of INTEREST What services are you interested in? * 1:1 Coaching Group Coaching Workshops / Facilitations (Leadership , Problem-Solving, Team Alignment) Speaking Engagements Other Other (please specify) ADDITIONAL INFORMATION What is the primary goal you'd like to achieve through these services? * Preferred Mode of Delivery? * Online In-Person Hybrid Estimated Timeline for Engagement As soon as possible 1 - 3 months 3 - 6 months 6 - 12 months Not sure yet Budget $2,500 - $5,000 $5,000 - $7,500 $7,500 - $10,000 $10,000 - $15,000 $15,000 - $20,000 How did you hear from us? Social Media Website Referral Event Other Anything else you would like to share? AGREEMENT and SUBMISSION By submitting this form, you agree to be contacted by Bethany Daley for follow-up. * I agree Please confirm your details are accurate and complete. * I confirm Thank you for taking the time to fill out this form. Bethany will be in touch. Thank you for taking the time to fill this form out. We have begun the process…let us see where this leads.Cheers!