Client Intake Form - 2023
All information requested is held under STRICT CONFIDENCE and collected only for the purposes of providing Jody Yaa Consulting with the information required to provide a quote or direct service delivery (with the exception of information required to be released to potential funders for grant writing services, sponsors, or collaborative partnerships). Disclosure verification must be provided by client prior to releasing information for the purposes noted above.
Legal Organization / Business Name: *
Does the organization / business go by a different name publicly? If so, please provide the name:
Mailing address:  *
Organization / business Registration Date: (if unsure, provide approximate date)
Current Status: *
Business Registration Type: *
Master Business Licence Number (if applicable)
Charitable Number (if applicable)
If you do not have charitable status, do you have a Trustee or Mentorship organization? *
Elevator Pitch: How would you describe in TWO or THREE short descriptive sentences, what the organization or business is all about? (consider the who, what, where, when and why, along with what makes your service unique) 
Is there a Mandate, Vision, key deliverables/outcomes or Impact Statement? If so, please provide below:
Online Presence - please provide your website address and  social media handles (Instagram, FB, Twitter, Linkedin, etc): *
Do you PRIMARILY provide services to any of the following communities? *
Is your organization / business Black owned, Black-led or Black-serving? (over 50% representation in front-line/middle & senior management as well as at the board level) *
Where is your organization / business providing services (currently or aspiring): *
Are services provided: (currently or aspiring) *
What are potential areas of support Jody Yaa Consulting could assist you with? *
Do you have any immediate concerns, challenges or time sensitive action items you are hoping to receive specific support with? If so, please provide brief, clear details outlining each item:
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