Intake Form: Executive Retreat for Organizational Healing

March 31 - April 5, 2023 | Riviera Nayarit, Mexico

Welcome! We look forward to the possibility of you and/or your team participating in our spring 2023 retreat. To help us understand the scope of your organization's needs and confirm your eligibility, please respond to the questions below. There are 15 in total. Please give yourself approximately 10 minutes to complete them. Anything you share will remain confidential.

Next Steps: Once we receive your Intake Form, a member of our Bruno Ford team will email you to schedule a free, 30-minute Info Session to further discuss registration and participation. To be considered to participate in the Executive Retreat for Organizational Healing, you must first join an Info Session. The session will be 1:1 with a Bruno Ford facilitator and completely confidential. If you qualify to participate in the retreat, the Bruno Ford team will email you the necessary links to complete your registration and make your payment.

Thank you for your time and interest.

In Gratitude,

Kali Mincy

Principal, Bruno Ford Consulting Group LLC

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* First Name

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* Last Name

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* Preferred Name (Optional)

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* Organization Contact Information

Note: If you aim to participate without employer sponsorship (e.g., if you're an individual, entrepreneur or independent consultant who'd cover your own costs), please provide your personal contact information.

Title

Company

Industry

City/Town

State/Province

Country

Email Address

Mobile Number

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* Info Sharing: How did you first find out about the Executive Retreat for Organizational Healing in Riviera Nayarit, Mexico?

Direct Email (Bruno Ford Consulting Group)

Direct Email or Call (Kali Mincy)

Direct Email or Call (Diana Noriega)

Instagram

Website (Bruno Ford Consulting Group)

Other (please specify)

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* Headcount: How many employees are you interested in registering for the retreat?

	Headcount
Executives	Executives Headcount menu
Senior Leaders	Senior Leaders Headcount menu
Managers: High-Potentials Defined: desires and is tracking to be promoted two or more positions in an accelerated timeframe	Managers: High-Potentials Defined: desires and is tracking to be promoted two or more positions in an accelerated timeframe Headcount menu
Managers: High-Performers Defined: consistently exceeds expectations; known to deliver on challenging projects with minimal direction	Managers: High-Performers Defined: consistently exceeds expectations; known to deliver on challenging projects with minimal direction Headcount menu

Total Number of Participants

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* Business Area: Function/Sub-functions of the employee(s) who would participate in the retreat (Select All That Apply)

Communications

Finance

Government/External Relations

Legal

OD/OE

R&D

Strategy

Other (please specify)

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* Demographics: What's the racial demographic(s) of the employee(s) who would participate in the retreat?

	Number of People
American Indian or Alaska Native	American Indian or Alaska Native Number of People menu
Asian or Asian American	Asian or Asian American Number of People menu
Biracial	Biracial Number of People menu
Black or African American	Black or African American Number of People menu
Latino/a/x/e	Latino/a/x/e Number of People menu
Middle Eastern or North African	Middle Eastern or North African Number of People menu
Multiracial	Multiracial Number of People menu
White	White Number of People menu

How I/Colleagues Identify (if not listed above):

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* Business Case: What’s your inspiration for participating in the Executive Retreat for Organizational Healing now? (Select 2-3)

A Strategic Initiative

Affinity Group or Employee Resource Group

Board Development + Governance

Employee Relations Issue(s)

Performance Improvement

Personal Skill Development Related to DEIB

Recent or Upcoming Executive Transition

Recent or Upcoming Promotion

Recent or Upcoming Restructure/Reorganization

Results of a 360 Assessment

Results of a Performance Review

Results of a Staff Satisfaction Survey

Succession Planning/Talent Planning

Other (please specify)

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* Org Learning + Healing for DEIB: What retreat topics would best support learning + healing in your organization so that stakeholders make progress toward DEIB goals? (Select 3-4)

Change Management for Diversity, Equity, Inclusion + Belonging

Compassion + Grace at Work

Creating Shared Understanding

Cultural Humility

Dominant Culture Norms That Prevent DEIB Progress

Establishing a DEIB Vision

Implicit Bias

Microaggressions

Mindfulness + Authenticity at Work

Navigating Difficult Conversations

(Re)Building Trust

Setting + Honoring Boundaries

Setting Clear Expectations for DEIB

Stakeholder Alignment

Other (please specify)

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* Previous Frameworks: In the last 18 months, what assessments have been completed by the employee(s) who'd participate in the retreat, if any? (Select All That Apply)

Note: Your answer will not impact an employee's ability to participate.

360

A Performance Review

Caliper

CliftonStrengths (formerly StrengthsFinder)

DiSC

Hogan

MBTI

None

I Don't Know

Other (please specify)

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* Scheduling Info Session: To be considered to participate in the Executive Retreat for Organizational Healing, you must join a free 30-minute Info Session. The session will be 1:1 with a Bruno Ford Facilitator and completely confidential.

What 3 availabilities do you have for your Info Session this week or next to discuss retreat registration and/or participation?

To Know + Understand: Your Info Session will cover
- Your DEIB Education, Awareness + Experience to Date
- Your Organization's DEIB Strategic Goals + Accomplishments
- Learning Goals + Needs
- Workshop Content + Coaching Add-On
- Healing Activities
- Your Organization Requirements (e.g., approvals, invoicing)
- Payment Terms

Date / Time (Eastern Time)

Date

Time

AM/PM

Date / Time (Eastern Time)

Date

Time

AM/PM

Date / Time (Eastern Time)

Date

Time

AM/PM

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* Participation Approval: Does your retreat participation require the approval of an individual or department within your organization?

Yes -- And I have approval already.

Yes -- But I need to get approval.

No -- I can register when I want to.

Other (please specify)

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* Payment Processing: If retreat payment(s) would be processed by an individual within your organization besides you, please provide the point of contact.

Name

Job Title

Department

Phone

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* Preferred Contact Method(s): If you qualify to participate in the retreat, the Bruno Ford team will provide details when needed. In such cases, what's the best way to contact you about time-sensitive info requests + retreat updates?

Text Message

Phone Call

To Receive Texts: If you prefer text messages for time-sensitive communications, please include the best phone number below (if different from above).

Intake Form: Executive Retreat for Organizational Healing

March 31 - April 5, 2023 | Riviera Nayarit, Mexico

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* First Name

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* Last Name

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* Preferred Name (Optional)

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* Organization Contact InformationNote: If you aim to participate without employer sponsorship (e.g., if you're an individual, entrepreneur or independent consultant who'd cover your own costs), please provide your personal contact information.

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* Info Sharing: How did you first find out about the Executive Retreat for Organizational Healing in Riviera Nayarit, Mexico?

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* Headcount: How many employees are you interested in registering for the retreat?

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* Business Area: Function/Sub-functions of the employee(s) who would participate in the retreat (Select All That Apply)

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* Demographics: What's the racial demographic(s) of the employee(s) who would participate in the retreat?

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* Business Case: What’s your inspiration for participating in the Executive Retreat for Organizational Healing now? (Select 2-3)

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* Org Learning + Healing for DEIB: What retreat topics would best support learning + healing in your organization so that stakeholders make progress toward DEIB goals? (Select 3-4)

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* Previous Frameworks: In the last 18 months, what assessments have been completed by the employee(s) who'd participate in the retreat, if any? (Select All That Apply)Note: Your answer will not impact an employee's ability to participate.

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* Participation Approval: Does your retreat participation require the approval of an individual or department within your organization?

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* Payment Processing: If retreat payment(s) would be processed by an individual within your organization besides you, please provide the point of contact.

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* Preferred Contact Method(s): If you qualify to participate in the retreat, the Bruno Ford team will provide details when needed. In such cases, what's the best way to contact you about time-sensitive info requests + retreat updates?

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* Additional Insights: What details or context would you like to share before your 30-minute Info Session?

* Organization Contact Information

Note: If you aim to participate without employer sponsorship (e.g., if you're an individual, entrepreneur or independent consultant who'd cover your own costs), please provide your personal contact information.

* Previous Frameworks: In the last 18 months, what assessments have been completed by the employee(s) who'd participate in the retreat, if any? (Select All That Apply)

Note: Your answer will not impact an employee's ability to participate.