U.S. Small Business Administration

Counseling Information Form

Client Counselor Record

First Name *

Middle Name

Last Name *

Email *

Phone

I confirm that I want to receive content from this company using any contact information I provide.

Address

Contact Type (Specific)

Language Preference *

English

Spanish

Stage of Business *

Exploring

Startup

Existing

In Business? *

Yes

No

Business Start Date *

Reportable Impact *

Yes

No

Date of Reportable Impact

Currently Exporting (sba) *

Yes

No

Full Time Employees:

Part Time Employees:

1099 Contractors:

Total number of employees engaged in exporting (Full & PT, SBA)

Gross Revenue/Sales $ (recent full business year)

$

+Profits/ -Losses

$

Amount of gross revenues/sales related to exporting (sba)

$

SBA or Resource Partner Contributed to the Following:

Number of SBA Loans (sba)

$

Total amount of SBA Loans (sba)

$

Amount of Equity Capital Received (sba)

$

Number of non-SBA Loans (sba)

$

Amount of Annual Value of Government/Subcontracts Received

$

Number of Government Contracts/Subcontracts Received (sba)

$

Date Counseled: *

Type of Meeting? *

Face to Face

Online (Virtual)

Telephone

Language Used: *

English

Spanish

Other

History *

New Case

Follow -Up

One Time

Nature of Counseling (Counselor Provided) *

Counselor(s) Name: *

Contact Hours (total contact hours that a client received) *

Prep Hours (total amount of preparation spent by all counselors for a client) *

Travel Hours (total amount of time it takes to travel to a client's location for counseling)

Did more than one Counselor participate in this counseling session? *

Yes

No

If there was more than one counselor, who was the secondary counselor in the session?

Counseling Notes: *

Recommendations and Information Shared with Client

Follow Up Actions & Next Steps