Questionnaire

Assessment Intake Form
Today's Date & Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Name

First NameLast Name
Title/Role
Email
example@example.com
Name of your company
Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website address:
How long has your company been in business? (Use date when business was registered only)
Is your company certified? If yes, please specify the certification and registration authority.
Do you evaluate your program, service or project? If yes, what measures do you use (ie. surveys and what kind of data do you collect? Please be detailed and include if you use an evaluator)
What tax year have you most recently filed?
Do you have a comprehensive organizational budget?

If applying for funding opportunity, please advise if you have reviewed the application and can confirm your organization meets the eligibility requirements outlined in the grant opportunities. If you're not applying for funding, put NA.
If you responded "Yes" in the prior question, please identify if you meet the eligibility requirements.
If you answered "Yes" to questions above, please answer these questions.
Have you started developing a budget for your project?
If yes, please share a high-level overview.
Are you seeking funding from multiple sources for this project?
If yes, please provide details.
Have you started drafting a grant proposal or narrative for your project you are seeking funding for?
If yes, please provide a brief overview of your project's significance and alignment with the grantor's mission.
Please include any additional comments or information (Optional)

What overall success and or challenges are you experiencing with your company related to grant needs? Please be detailed:
Additional recommendations and summary from Mended Wing Consulting, LLC: (MWC will complete this section)
Next Session: (do not fill out. MWC completes)
Action Steps for Mended Wing Consultant: (do not fill out. MWC completes)
Action Steps for Client: (do not fill out. MWC completes)
Disclaimer: All intellectual and shared content between client and Mended Wing Consulting, LLC is protected under the confidentiality agreement. The information in this document, inclusive of attachments, is designated solely for the mentioned parties and may contain privileged, confidential content safeguarded from unwarranted disclosure.
Signature
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Assessment Intake Form