INSTRUCTIONS: All parts of this Form to be completed for new clients.

Block #

Requirement

Explanation

PART I. Client Request for Counseling – To be completed by client

3

Client Name

Self-Explanatory

4

Email

Email address. If not available use First name.Lastname@yyy.yyy.

5

Telephone

The first # might be a home or business number. The second could be a cell phone number. Only one # is required.

6

Fax Number

(not required)

7

Street Address/PO Box

Home, or business address if currently in business.

8

City

Home city, or business city if in business.

9

State

State of home or business location.

10

Zip plus 4

ZIP required. Plus 4 not required.

11

Disclaimer

Required

12

Preferred Date & Time for Appointment

(not required)

NOTE: Typing your name and date in Field 13, below, is the same as inserting your signature and is required. Both the MS Word and the on-line versions of this document are sent by email to the SCORE Medford Office and will be time stamped the same as any email message The MS Word version must be sent as an attachment to an email sent by the client, while the on-line (HTML) version will be sent when the "Submit Form" button is activated by the client.

13

Client Signature/Date

Required

PART II. Client Intake – To be completed by client

14

Race

Self-Explanatory

15

Ethnicity

Self-Explanatory

16

Gender

Self-Explanatory

17

Disability

Self-Explanatory

18.

Veteran Status

Self-Explanatory

18a

Military Status

Self-Explanatory

19

What inspired you to contact us?

More than one box can be checked.

20

Are you currently in business?

If NO, skip to 30.

21

Name of Company

Self-Explanatory

22

Type of Business

Select only one category.

23

Business Ownership

Total ownership should = 100%.

24

Month & Year Business Started

default is January of current year.

25

Do you conduct business online?

yes or no.

26

Is this a home-based business?

yes or no.

27

Total number of employees

Total number, full and part time, at present

28

For your most recent full business year, what are your gross revenues, profits or losses?

Self-Explanatory

29

Legal entity of your business?

If other is checked, please specify.

30

Nature of the counseling seeking?

If specific assistance is required, please check "Other" and provide reason.