Assessment Questionnaire (Company, Agency Or Organization)

cheryl@wellnesslinkage.com

510-588-8484

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Company Name *

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone Number *

Area Code *

Best Time To Contact *

Point of Contact Name (POC) *

How did you hear about this Agency?

Who will utilize these services? *

Clients
Staff
Employees
Other

Roughly how many will be serviced? *

1-5
6-10
11-15
16 or more

NOTE: Answer all the below questions in 5 sentences of less!

What services are you needed from this project and what are your needs?

What challenges or problems do you feel you are facing that prevent you from reaching your goals?

Who is the decision-makers, and what is the approval process? (Please provide Name, Contact Number, Job Title, Email Address)

What are your expectations for this project? (if you are unsure, please state)

When do you want to start this service?

What do you envision as success for the service you are needing? (if unsure please state)

Is there a timeframe in which you will need to close and/or complete the services that you need?

Completing this basic data collection presented to Wellness Linkage Consulting is used to establishing a future consulting/counseling feedback ONLY. This information provided by you will be confidential and does not constitute as a Service Contract or Agreement. Thank You

Assessment Questionnaire (Company, Agency Or Organization)

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