EBIM™ — Diagnostic Intake Form

Please complete this form as accurately as possible.

This intake is used to determine:

whether your issue fits the EBIM framework
which diagnostic tier applies
whether additional review may be needed

Submitting this form does not guarantee service acceptance.
Diagnostic tier and final scope are confirmed after intake review.

Full Name

Email

Phone Number

(Optional but recommended)

Organization Type:

Environment Identification

Select All That Apply:

Primary Area of Concern

Select All That Apply:

Primary System

Apply: concern, ACKNOWLEDGMENT

What prompted this review?

Current Condition:

Select All that apply:

Please describe the issue, concern, discrepancy, or condition you would like reviewed.

SERVICE ACKNOWLEDGMENT

I have read and agree to the Service Acknowledgment.

By submitting this request, I acknowledge that EBIM Diagnostic Services provide evidence-based diagnostic reviews designed to identify documentation gaps, operational misalignment, control exposure indicators, traceability concerns, and governance-related observations based on the information provided. I understand that EBIM Diagnostic Services do not provide legal advice, determine legal liability, certify fraud, conduct law-enforcement investigations, guarantee outcomes, or replace the work of licensed attorneys, auditors, regulators, or government agencies. I acknowledge that service recommendations, diagnostic tier placement, and any potential escalation to EBIM-FRIT or CEI analysis will be determined following review of the submitted information. I certify that the information submitted is accurate to the best of my knowledge and that I have the authority to provide the documents and information included with this request. Submitting an Intake Form has a cost of $0.00.

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Your information is kept confidential and used only for the purpose of evaluating your request. Your information will not be shared.

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