COVID Navigation Intake
Complete a short intake form and schedule your COVID Navigation session after you complete the form. Thank you! All information provided is confidential!
1.
Please enter your name.
*
First Name
Last Name
2.
What is your company's name?
3.
What is your preferred email address to receive our email communications?
*
4.
What is your work phone number?
5.
How has the COVID crisis impacted your business?
6.
What are your needs?
Loan options
Grant opportunities
Help getting service or product online
Employee Mgmt Advice
Getting bills delayed
Legal Support
Urgent cash for personal needs
7.
Please describe any additional needs you may have.
8.
How many part-time jobs (less than 35 hours per week) does your business have?
9.
How many full-time paid employees (35 hours or more per week) does your business have?
10.
What legal structure do you have for your business? (Sole proprietorship, LLC, Partnership, Corporation etc.)
Sole proprietorship
LLC
Partnership
Corporation
Cooperative
Not for profit
None
Other
11.
Please provide your annual sales revenues (if any) for the last fiscal/calendar year.
12.
How did you hear about us? If referred, please include the specific organization name.
Demographics
This demographic information is optional, but it will help us make the appropriate matches for grant and loan opportunities.
We also collect certain demographic information in order to provide anonymized statistics about the prevalence of various types of entrepreneurs in the Bay Area to service providers and funders.
All information provided is confidential.
13.
How do you describe yourself? (Check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Latinx
Middle Eastern
Native Hawaiian or other Pacific Islander
White
Other
14.
What is your ethnicity?
Hispanic or Latinx
Non-Hispanic or Non-Latinx
15.
Please enter your home address five digit zip code.
16.
Please enter your business address five digit zip code.
17.
What is your birthdate?
18.
Do you consider yourself to be LGBTQ?
Yes
No
19.
Which gender do you identify most?
Female
Male
Gender Non-conforming
Prefer not to answer
20.
Do you identify as an immigrant?
Yes
No
Prefer not to answer
21.
What is your annual household income?
<$10K/year
$10k-$19K/year
$20K-$29K/year
$30K-$39K/year
$40K-$59K/year
$60K-$74K/year
$75K-$99K/year
$100K+/year
22.
How many people live in your household?
23.
How many children under 18 live in your household?
Hit the submit button and you are done. Don't forget to schedule a session with us here: https://bit.ly/schedulecovidsession