Performance Intake

Performance Powered By Resilience™

Thank you for your interest in working with Bella Medical Associates. This intake helps us understand your organization’s priorities, context, and goals so we can prepare a focused, high-value leadership briefing.

Completing this intake does not represent a commitment. It supports an informed conversation about fit, scope, and next steps. Only a few questions are required; additional details are optional and help us tailor recommendations.

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Your Information

1. Organization or Agency Name

Please enter the full organization or agency name.

2. Your Name

First and last name.

3. Best Email to Reach You

Used only for follow-up and briefing coordination.

4. Your Role or Title

Helps us understand decision context.

Your Priorities

5. What best describes your reason for reaching out today? (Select all that apply) Choose what fits best. This helps us route your request appropriately.

Leadership or team coaching

Organizational wellness or performance strategy

Burnout prevention or workforce resilience

Speaking or executive briefing

Exploring options / not sure yet

Employee Wellness Program

Employee Wellness Medical Access; Does not replace primary care provider

Exploring options/ not sure yet

6. Current Challenges & Goals (Check all that apply) What prompted you to explore executive wellness or leadership support right now?

High turnover or resignation risk in key leadership roles

Visible burnout, fatigue, or declining performance in top performers

Visible burnout, fatigue, or declining performance in your team.

Recent leadership departures or medical leaves

Difficulty retaining high-potential leaders

Culture of overwork, "always-on" mentality

Board or C-suite directive to address leader wellbeing

Desire to differentiate benefits and attract/retain top talent

7. If not listed above, what challenge or opportunity prompted this inquiry?

A short response is fine.

8. What outcomes would make this engagement valuable for your organization?

Think in terms of performance, engagement, retention, or risk reduction.

9. Which areas feel most important to address right now? (Select all that apply) You can clarify later.

Leadership resilience / Team effectiveness

Workforce stress or burnout

Retention or engagement concerns

Performance under pressure

Culture or communication gaps

Organizational change or transition

Employee Wellness Program

Exploring options/ not sure yet

Not sure yet — seeking clarity

10. In the last 12 months, have you experienced:

Leadership turnover? Yes

Leadership turnover? No

Team member turnover? Yes

Team member turnover? No

If yes, how many key leaders and team members departed?

Medical leave or extended absences due to stress/burnout?

Yes No

Performance decline or "quiet disengagement" in mission-critical roles?

Yes No

11. What would success look like for you 3–12 months from now?

12. Leadership Tiers & Target Participants Which leadership tier(s) are you most concerned about or interested in supporting?

C-suite (CEO, CFO, COO, etc.)

Senior VPs / Executive Directors

Mid-level VPs or Directors

High-potential emerging leaders

Founders or owner-operators

Other

If Other, please list.

13. How many leaders / team members are you considering for an initial pilot or program?

1 leader

2 leaders

3–5 leaders

6–10 leaders

10+ leaders

1-5 team members

5+ team members

Still exploring

14. Do you have specific individuals in mind, or are you looking to identify high-risk leaders or team members first?

Specific individuals identified Need help identifying who is at highest burnout risk Combination of both

Scope & Timing (Optional)

15. Preferred engagement format (if known) You can update this later.

Virtual In-person Hybrid Not yet decided

If in-person, please specify the venue:

Location

City

State

Zip code

16. Estimated audience size (if applicable)

Approximate is fine.

17. Target timeline or timeframe

Tentative dates are okay.

Questions 18-25 (Optional)

Leadership or team coaching, Organizational wellness or performance strategy, Speaking or executive briefing:

18. How does finding a solution for your teams’ performance and wellness align with your business or organization’s mission, vision, values, productivity statement, primary goals and top priorities for the year?

19. What significant benefits or measurable impacts do you anticipate from addressing this issue within your business, organization or team?

20. What additional information would you like to share to ensure you gain the best experience from this holistic consulting solution?

Yes No Unsure

Budget range & Decision-Making (optional — helps us tailor recommendations)

21. Which option is your business or organization ready to invest? Optional. Select a range if available.

Under $10,000 $10,000–$25,000 $25,000–$50,000 $50,000–$100,000 Over $100,000 Not yet determined

22. Who are the key decision-makers for this investment?

HR / Chief People Officer

CEO / President

CFO / Finance

Board of Directors

Other:

23. What would make this investment feel "unquestionably worth it" to your leadership team?

Additional Information

24. Anything else you’d like us to know?

Optional — share only if helpful.

25. How did you hear about our services?

This intake supports a strategic discussion and does not obligate your organization to proceed.

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