Questionnaire

Assessment Intake Form
Today's Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Name*

First NameLast Name
Email*
example@example.com
Phone Number: *
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)*
What tax year have you most recently filed?*

20212022current year (not listed)N/A
Do you have a comprehensive organizational budget?*

YesNoNeed help with creating a budget

Do you meet the eligibility requirements outlined in the grant opportunities you've identified?*
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 secured grant funding? If so, please provide month/year and amount. If not, please put N/A.*
Have you started drafting a grant proposal or narrative for your project?
If yes, please provide a brief overview of your project's significance and alignment with the grantor's mission.
Additional Comments or Information (Optional)

What overall success and or challenges are you experiencing with your company related to grant needs? Please be detailed:*
MWC-recommendations on potential strategic solutions based on needs assessment: (MWC consultant team only) DO NOT FILL OUT
Additional recommendations and summary from Mended Wing Consulting, LLC: (MWC will complete)
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*

Powered by Jotform SignClear
Should be Empty:

Assessment Intake Form