Company Name
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Full Name of Representative Completing this form:
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Email
*
Company Website:
*
Company Size:
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Select one
1-50 employees
50-100 employees
100-500 employees
500-1000 employees
1000-5000 employees
5000+ employees
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Approximate number of female employees:
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Primary age of your female workforce:
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20's-30's
40's
50's
60's
Very mixed ages
Industry
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Select the closest match
Technology
Healthcare
Finance/Banking
Professional Services
Education
Retail/Hospitality
Manufacturing
Government/Public Sector
Non-Profit
Restaurant/Food Industry
Other
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Company Location
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How would you like this workshop presented?
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Select your company preference
Virtual Presentation
In Person
Hybrid
Not sure yet
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What prompted you to explore hormone health education for your team?
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Which of these challenges are you currently experiencing?
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Unexpected turnover with female employees
Inconsistant productivity or performance
Increased absenteeism or sick days
Employees requesting accommodations for health issues
Difficulty retaining women in leadership pipeline
Employee feedback requesting more women's health support
Rising healthcare costs
Low engagement or morale among female employees
What would success look like for you after implementing this program?
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Do you currently have wellness programs or benefits in place?
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Yes, comprehensive wellness programming
Yes, some wellness benefits
Limited/basic wellness offerings
No, we're just getting started
Not sure
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If yes, what is currently working well?
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What do you feel like is missing or not working?
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Which Program tier are you most interested in?
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Foundations - single 45 minute presentation
Empowerment Series - 3 or 6 session deep dive for comprehensive education
Transformation package - empowerment series + coaching
Not sure yet, would like to discuss options
Custom - we have specific needs
Ideal timeline for implementation:
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ASAP - within the next month
1-3 months
3-6 months
6-12 months
No specific timeline
What is your budget range for this type of program?
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Under $5,000
$5,000 - $10,000
$10,000-$20,000
$20,000-$50,000
$50,000+
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How did you hear about us?
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Google search
LinkedIn
Referral from colleague
Referral from another company
Social media
Conference or event
Article or podcast
Personal contact
Other
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What potential for productivity and efficiency do you see that is not yet being reached by women in your company?
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Is there anything else we should know about your company, culture, or specific needs?
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