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First Name

Last Name

Impact Assessment

Please check all that apply:

Property Loss (e.g., damage to building, inventory, equipment)

Employee Loss (e.g., staff displacement, layoffs)

Customer Loss (e.g., decline in foot traffic, contract cancellations)

Financial Loss (e.g., revenue decline, increased expenses)

Other

Support Needed

What resources would help your business recover? Select all that apply:

Insurance Assistance (e.g., filing claims, navigating policies)

Rebuilding Support (e.g., construction, relocation)

Business Pivots (e.g., new strategies, alternative revenue streams)

Marketing Support (e.g., outreach, social media, customer engagement)

Equipment Replacement (e.g., tools, machinery, supplies)

Coaching & Mentoring (e.g., business strategy, leadership support)

Professional Training (e.g., new skills, certifications)

Grant Assistance (e.g., identifying and applying for grants)

Low-Interest Loan Options

Investment Opportunities (e.g., business partnerships, funding sources)

Mental Health Support (e.g., stress management, counseling)

Other

Willingness to Connect

Would you be open to meeting with our team to discuss potential support?

Yes

No