ImJustJay Consulting

Client Intake Form

Complete all sections to help us understand your business needs.

1Type of Contact

Face to Face

Online

Telephone

IClient Information

Full Name (Last, First, MI)*

Email Address*

Phone (Primary)

Phone (Secondary)

Street Address / PO Box

City

State

Zip

IIDemographics

Race (select all that apply)

Asian

Black or African American

Native American or Alaskan Native

Native Hawaiian or other Pacific Islander

White

Ethnicity

Hispanic Origin

Not of Hispanic Origin

Gender

Male

Female

Non-Binary / Other

Do you consider yourself a person with a disability?

Yes

Veteran Status

Non-Veteran

Veteran

Service-Disabled Veteran

Referred By (select all that apply)

Word of Mouth

Internet / Social Media

Magazine / Newspaper

Television / Radio

Business Owner

Educational Institution

Other

IIIBusiness Information

Are you currently in business?

Yes

IVNature of Assistance Requested

Start-Up Assistance (How Do I Start A Small Business)

Business Plan & Marketing Plan

Financing/Capital (Loan, Building Equity Capital)

Managing A Business/Revamp Your Business

Human Resources/Managing Employees

Public Relations/Branding

Business Accounting/Budget

Cash Flow Management

Web Design & Graphic Design

Marketing/Sales (Promotion, Market Research, Pricing)

Government Contracting (Including Certifications)

Digital Transformation (Geofencing, NFC, AR & More)

Buy/Sell Business/Franchising

Technology/Computers

eCommerce (Using The Internet To Do Business)

Farming & Solar Energy

BlockChain/NFTS

Describe Specific Assistance Requested

Additional Notes

Your information is kept confidential and used solely for consulting purposes.