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Client Intake form
Step
1
of
5
20%
Client Information
Please provide some information about the client.
Type of Client
Training and Technical Assistance Client
Technical Assistance Client
New Enrollment Existing
New Enrollment Start-Up
Client #
Name
First
Middle
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
Phone
Date of Birth
MM slash DD slash YYYY
Additional Client Information
The more information you can provide about yourself, the better we can assist you.
Service Provided
In-Person
Online
Phone
Best Time to Reach You
Morning
Afternoon
Evening
Marital Status
Single
Partnered
Married
Separated
Divorced
Widowed
Employment Status
Employed Full Time
Employed Part Time
Unemployed
Self Employed Full Time
Self Employed Part Time
Displaced Homemaker
Public Assistance
Retired
Do you have any disabilities?
Yes
No
Race/Ethnicity
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Non-hispanic or Latino
Native Hawaiian or Pacific Islander
White
Asian
Highest Education Attained
Grade School
Junior High School
High School/GED
4 Year College/University
Graduate
Doctorate
Primary/Preferred Language
English
Spanish
Are you computer savvy?
Yes
No
Business Information
Describe some details about your business.
Business Name
Are you currently in business?
Yes
No
Type of Business
Retail
Service
Manufacturing
Construction
Finance, Insurance, Real Estate
Wholesale, Distribution
Unknown at this time
Stage of Business
Thinking of Starting a Business
In Process of Starting or Acquiring a Business
Currently own a business that has been in operation for less than 1 year
Currently own a business that has been in operation for 1 to 5 years
Currently own a business that has been in operation for more than 5 years
Has a business plan been assembled?
Yes
No
Do you have a social media presence?
Yes
No
Business Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Additional Business Information
Tell us more about the business and how it operates so we can better assist you.
Business Facility
Home-based
Rent Outside Facility
Own Outside Facility
Unknown at this Time
Legal Entity of Business
Sole Proprietorship
Corporation
S-Corporation
Partnership
LLC
Date Business Started
MM slash DD slash YYYY
Business EIN
Products/Services
Percentage (%) Male-Owned
Please enter a number less than or equal to
100
.
Percentage (%) Female-Owned
Please enter a number from
0
to
100
.
Number of Full-time Employees
Number of Part-time Employees
Income Generated by Business
Main Source of Income
Supplementary Income
Unknown at this Time
Gross Revenue/Sales in Last Year
Profits/Losses in Last Year
Does the owner have financials for the business, and can he/she account for past business transactions?
Yes
No
Designated Group/Status
Veteran
Dislocated Worker
Disabled individual
ONA
New Mentees
Client Mentors Assigned
MWBE Certification Status
Certified
Not Eligible
Application Rejected
Certification Denied
Re-cert Application in Process
Have Not Applied
Application in Process
Certification Revoked
How can we help you?
Tell us a little more about how WHIDC can help you and your business.
What is the nature of counseling you're seeking?
Start-up Assistance
Business Plan
Financing/Capital
Managing a Business
Cash Flow Management
Tax Planning
Marketing / Sales
Government Contracts / Certification
Technology
Legal Issues
Buy / Sell Business
Business Accounting / Budget
Other
Other Counseling Needed
Add
Remove
Have you received business counseling in the past?
Yes
No
Where did you receive this counseling?
I grant permission to Washington Heights and Inwood Economic Development Corporation (WHIDC) to use my person,company name,pictures and information regarding the general nature of my business and the services provided by a representative of WHIDC. In addition to granting access to any funders/sponsors that support the funding of programs that WHIDC represents.
(Required)
Yes, I agree.
Signature
(Required)
Date Signed
(Required)
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.
