CJHA - DIAGNOSTIC INTAKE FORM

DIAGNOSTIC INTAKE FORM

SECTION A: Business Snapshot

Registered Representative First Name*

Registered Representative Last Name*

Registered Representative Primary Email*

Registered Representative Phone

Preferred Method of Contact

Registered Legal Name

Are you representing a company? If yes, complete this field with your official Company Name. If you are not representing a company, then please enable the switch below labeled "I'm not representing a Company".

Registered Address

Industry

SECTION B: Financial & Cashflow Signals

Average monthly revenue (Estimate)

Average monthly expense (Estimate)

Current Cashflow Pressure

Missed Payments in Last 6 Months?

Creditor / SARS Pressure Present?

SECTION C: Systems & Operations

Accounting Software Used

Is your inventory Managed?

What Inventory System Are You Using?

Your Approximate Number of SKUs

SECTION D: Governance & Decision Quality

Do you receive management accounts?

Do you have a budget or forecast?

How often is strategy reviewed?

SECTION E: Strategic Intent

Primary Reason for Contacting Us

Biggest ongoing challenge

Main goal for the next 12 months

SECTION F: Advisory Readiness

Interest in advisory support

Yes

Interest in systems & automation

Yes

Willingness to engage in turnaround support if needed

SECTION G: Confirmation

Confirmation

This is a paid diagnostic assessment (R3,500 excl VAT).

Confirmation

This is a paid diagnostic assessment (R3,500 excl VAT).
The session includes a 90-minute review + a written improvement roadmap.
This form helps us prepare so that your session is high-value and actionable.