SECTION 1 - Client Profile

Full Name *

Preferred Name

Phone Number *

Email Address *

City / Town (NJ County)

How did you hear about KimKebi Solutions?

If referral - who referred you?

SECTION 2 - Your Background and Experience

Current occupation / day job

How many years have you worked in healthcare or human services?

Describe your direct care or administrative experience

Have you ever owned or managed a business before?

Yes - still operating Yes - no longer active No

If yes - briefly describe

SECTION 3 - Current Business Formation Status

Answer as accurately as possible - there are no wrong answers. This helps us know exactly where you are today.

What type of agency are you looking to build?

Non-Medical / Personal Care Medical / Skilled Nursing Both - starting non-medical, expanding to medical

Business Name (if established)

Purpose as stated on your NJ Certificate of Formation (copy exactly as filed)

Planned Business Activities (what your agency will actually do)

Does your Certificate of Formation include DDD / direct care language?

Yes - they match No - needs updating Not sure

Business Structure

State of formation

New Jersey Another state Not yet formed

Do you have a Federal EIN?

Yes No Applied but not received Not sure

Do you have a business bank account open?

Yes No - plan to open soon No - unsure how

Do you have an NPI (National Provider Identifier)?

If yes - NPI number (optional)

If no NPI - have you started the application process?

Yes - in process No - not started Did not know I needed this

Do you have professional liability insurance in place?

Yes - active policy No - but aware I need it No - did not know I needed it Currently getting quotes

If yes - insurance provider and coverage amount

Do you have a Medicaid provider number / NJ Medicaid enrollment?

Yes No - not started In process Not sure what this is

Do you have a business address? (P.O. Box does NOT qualify for DDD)

Yes - physical office Yes - home address No - still looking Using P.O. Box (needs correction)

SECTION 4 - NJ DDD Credentialing Status

This section helps determine where you are in the DDD approval process and what steps remain.

Have you started the NJ DDD credentialing / provider application process?

Yes - actively in process Just beginning Not yet started Not sure where to start

Have you submitted anything to DDD yet?

No Letter of Intent Initial Application Some documents Full application submitted

Have you received any communication from DDD?

No communication yet Yes - confirmation Yes - requests for info Yes - approval / denial

Have you reviewed the NJ DDD Policy Manuals?

Yes - in detail Started but not finished No - not yet Did not know these existed

Do you have access to the DDD Provider Portal / iRecord?

Yes - active access Applied for access No - not started Not sure what this is

Do you understand the background check process and timeline?

Yes - fully understand Somewhat No - need guidance

What is your timeline expectation for launching services?

DDD approval typically takes 4-6 months from LLC formation. The timeline depends on DDD review, background checks, and post-approval setup.

What services are you seeking to provide? (Check all that apply)

Community Based Supports (CBS) - Non-Medical / Personal Care Respite Services Day Program / Community Engagement Supported Employment Residential Services Skilled Nursing / Clinical Services (future goal) Other (describe below)

If other or future services - describe

SECTION 5 - Policies and Procedures - Where Are Your Thoughts?

DDD requires policies and procedures - but you typically build these AFTER your initial approval meeting with DDD. This section is just to see where your thinking is right now.

Have you started thinking about your agency policies and procedures?

Yes - researching Heard about them Not yet Did not know I needed these

Do you have any sense of what policies DDD requires?

Yes - I have a list Somewhat familiar No - I need guidance

Have you worked with anyone on policies before?

Yes No Considering it

Any questions or concerns about policies and procedures?

SECTION 6 - Staffing and Human Resources

Do you have any staff hired or identified?

Yes - already hired Yes - identified not hired No - will hire after approval Will start solo

What roles are you planning to fill? (Check all that apply)

Direct Support Professional (DSP) Program Manager / Supervisor Billing / Administrative Staff Registered Nurse (RN) Consultant Office Manager Other

Do you know the background check requirements for NJ DDD staff?

Yes - fully understand Somewhat No - need guidance

Are any planned staff already credentialed or certified?

Yes No Partially

SECTION 7 - Prior Consulting Experience

Have you worked with a consultant or coach on this agency before?

Yes No

If yes - what did they help you with?

What went wrong or what was missing?

What was promised that was not delivered?

SECTION 8 - Your Goals and Expectations

What is your number one goal for working with KimKebi Solutions?

What does success look like for you 12 months from now?

What are you most worried about in this process?

What have you already tried on your own?

How much time per week can you dedicate to building your agency?

Under 5 hrs 5-10 hrs 10-20 hrs 20+ hrs - full focus

How do you prefer to communicate? (Check all that apply)

Weekly 1-on-1 video calls Email with document reviews WhatsApp / text for quick questions Shared Google Drive / project management Combination of all of the above

Is there anything else you want me to know?

SECTION 9 - Readiness Self-Assessment

Rate yourself from 1 (not started / no knowledge) to 10 (fully done / very confident).

Area	Scale	Your Score
Business Formation	1 = Not started 10 = Fully set up
DDD Credentialing Knowledge	1 = No idea 10 = Deep knowledge
Policies and Procedures Awareness	1 = No awareness 10 = Fully informed
Staffing Readiness	1 = No staff planned 10 = Fully hired
Overall Confidence	1 = Very uncertain 10 = Very confident

KimKebi Solutions - New Client Intake and Readiness Assessment

Thank You!