Program Intake Form

Program Intake Form
Welcome!

We're excited to get to know you & your business! Before we get you connected with a Coach to learn more about our services, we want to learn a bit more about YOU!

Intake Form Instructions:
- This intake form is required to be completed prior to you scheduling your appointment.
- Complete all required questions of this intake form. Any field that has a * indicates a required field.
Contact Information
Name*

First NameLast Name
Business Name*
Business Owner Job Title (ex. CEO, Executive Director)*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Pronouns*

She/HerHe/HimThey/ThemOther
Business Owner Demographic & Business Overview
Business Industry Sector*

Accommodation, Restaurant and Food ServicesAdministrative and Support and Waste Management and Remediation ServicesAgriculture, Forestry, Fishing, and HuntingArts, Entertainment, and RecreationConstructionEducational ServicesFinance and InsuranceHealthcare and Social AssistanceInformation ServicesManagement of Companies and EnterprisesManufacturingMining, Quarrying, and Oil and Gas ExtractionOther Services (except Public Administration)Professional, Scientific, and Technical ServicesPublic AdministrationReal Estate and Rental and LeasingRetail TradeTransportation and WarehousingUtilitiesOther
Business Size (ex. Gross Revenue)*

Less than $50,000$50,001-$250,000$250,001-$1 Million$1,000,001 - $5 MillionOver $5 Million
Staffing Size*

N/A - Idea StageSelf Employed1-45-910-100Over 100Prefer not to answer
Business Owner Race**

AsianBlack/African AmericanHispanic/LatinoNative American/Native AlaskanNative Hawaiian/Pacific IslanderMultiracialPrefer not to answerOther
Business Owner Ethnicity**

Hispanic/LatinxNon-Hispanic/LatinxPrefer not to answer
Business Owner's Gender Identity*

FemaleMaleNon-BinaryOther
Preferred Language*

EnglishSpanishHmongSomaliOromoOther
What is your yearly household income? (ex. $50,000)*
What is the number of household members in your home? (ex. just you= 1, you & spouse = 2)*

12345678910Over 10
Tell us about your business?
Are you a current Business Owner or are you at the idea stage of launching your business?*

Current Business OwnerIdea Stage
What do you do? What products or services do you offer? (Please provide a brief description of your business)*
Business Website (if no website, enter N/A or insert social media links)*
Business Owner Support Needs
What are your business support needs? (Check all that apply)*

Business PlanFinancials/Pro FormaEmployee Engagement PlanExecutive CoachingLeadership DevelopmentProduct/Service RoadmapStrategic Plan/Growth StrategyOther
What pain points or challenges are you facing with your business?*
Please list your top business goal(s) or priority(ies) when it comes to working with Led by TRUTH.*
Why is now the right time to work with Led by TRUTH?*
Fill in the blank: I'll know I'm successful when...*
Please share any additional information you feel would be helpful for us to know.*
How did you hear about Led by TRUTH?*

Internet SearchFacebookInstagramLinkedInReferral and/or Word of MouthElevate HennepinACER (African Career, Education, Resource Inc.)ConnectUP! InstituteOther
Please list the name of the person and/or organization who referred you. (enter N/A if not applicable) *
Should be Empty:

Program Intake Form

Welcome!

Intake Form Instructions:

Contact Information

Business Owner Demographic & Business Overview

Tell us about your business?

Business Owner Support Needs