Client Intake Form

Contact Information

First Name

Last Name

Email Address

Phone Number

Date of Birth

Preferred Language

Preferred Contact Method

EmailPhone

Street Address

City

State

Zip Code

Business Overview

Please select the option that best describes where you are in your business journey

Prospective - You have a business idea and may have done some early research or created a sample product, but you haven’t officially registered your business or started making money yet.Pre-Start Up - You’ve started setting up your business (like registering it), and may be beginning to earn money or bring on your first employees.Start Up - Your business is up and running and starting to grow. You may be increasing sales, hiring staff, or expanding your space or services.Established - Your business has been operating for a while and is stable, though you may still be making improvements or changes over time.Transition/Stabilization - Your business may be facing challenges, like declining sales or uncertainty about the future, and could benefit from support to stabilize, restructure, or plan next steps.

Prospective

What type of business are you interested in starting?

If you selected "Other", please describe below:

Have you done any of the following?

Written a business planRegistered the businessEstimated startup costsNone yet

When do you hope to start the business?

Within 3 monthsWithin 6 monthsWithin 1 yearMore than a year away

What type of support do you need the most right now?

Briefly describe your business idea

Pre-Start Up

Business Name (if decided)

Business Email (if applicable)

Industry

If you selected "Other", please describe below:

Expected Start Date

What type of support do you need the most right now?

Briefly describe your business idea

Start Up, Established, Transition/Stabilization

Business Name

Business Email

Your Role in the Business

Business Address

Business City

Business State

Business Zip Code

Business Phone Number

Business Start Date

Industry

If other, please specify below

Business Entity/Type

Is this business your main source of income?

Is your business woman owned? (50% or more of the business is owned by a woman)

How much revenue did your business generate last year?

How many employees do you have?

What are your current business goals?

If other, please specify below

Contact Information