Financial Intake Form

If the form below looks strange, please turn your phone so your screen is wide.

What's your name? *

What is your date of birth? *

Phone number *

Email *

Type of work *

Marital Status *

What is your spouse's name? *

Spouse's Date of Birth *

Spouse phone number *

Spouse email *

Spouse type of work

Have you been through Financial Peace University? *

Yes
No
What's Financial Peace University?

What is your address? *

Address Line 1

Address Line 2

City

State

Zip Code

How many children or other dependants do you have? *

INCOME: What is your monthly net take-home pay? *

Do you have an irregular income? *

Do you use a monthly budget? *

SAVINGS: Do you have an emergency fund? *

How much is in the fund? *

Are you currently investing for retirement? *

What is your balance? *

What is your monthly contribution? *

Do you contribute to non-retirement savings? *

What is your balance? *

What is your monthly contribution? *

HOUSING: Do you rent or own? *

Rent
Own

Are you current on your payment? *

What are the total monthly payments for your rent/mortgage? *

CONSUMER DEBT: Do you have any vehicle Loans? *

Are you current on your payments? *

What are the total monthly payments of any vehicle loans? *

What is the total balance of all vehicle loans? *

What is the total balances due of all credit cards? *

What is the total balances due of all student loans? *

What is the total balances due of all taxes? *

What is the total balances due of all other consumer debt? *

What primary issue should we focus on during your coaching session? *

Budgeting
Real Estate
Dealing With Collectors
Wealth Building/Investing
Debt Elimination
Other

If you checked "other" above, please explain here *

List the top three concerns/questions related to your above selection: *

Are you currently working with any other financial advisor? *

If so, who, for what reason, and for how long? *

Religious Faith *

Christianity (Protestant)
Christianity (Catholicism)
Islam
Hinduism
Agnosticism
Buddhism
Atheism
Sikhism
Seventh-Day Adventists
Latter Day Saint
Judaism

Protestant Denomination *

Have you accepted Jesus as your Lord and Savior? *

Yes
No
Unsure

Present church affiliation or name of church you attend *

Please tell me about that... *

Legal Issues *

No
Yes, previously or currently

Charges *

Please explain. *

Serving Probation? *

Education Level *

Higher Ed - School Name *

Graduation Date *

Are / Were you a service member? *

Yes, currently
Yes, previously
No

Date of enlistment *

Date of discharge *

Type of Discharge *

General Discharge
Honorable Discharge
Bad Conduct
Dishonorable Discharge
Other Than Honorable (OTH) Discharge

What Branch? *

Army
Navy
Air Force
Marines
Cost Guard
Space Forces
Other

What Rank? *

Are you satisfied with your present occupation? *

What and with whom is your current occupation? *

When did you start working with your current employer? *

Are you satisfied with your present income? *

Is there anything else you want your Financial Coach to know?

How did you hear about the Financial Coach at the CV Biblical Counseling Center? *

Captcha *

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