Financial Intake Form Please enable JavaScript in your browser to complete this form.Personal Information - Step 1 of 8If the form below looks strange, please turn your phone so your screen is wide. What's your name? *What is your date of birth? *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone number *Email *Type of work *Marital Status *SingleEngagedMarriedSeparatedDivorcedWidowedWhat is your spouse's name? *Spouse's Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse phone number *Spouse email *Spouse type of workHave you been through Financial Peace University? *YesNoWhat's Financial Peace University?What is your address? *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHow many children or other dependants do you have? *NextINCOME: What is your monthly net take-home pay? *Do you have an irregular income? *YesNoDo you use a monthly budget? *YesNoSAVINGS: Do you have an emergency fund? *YesNoHow much is in the fund? *Are you currently investing for retirement? *YesNoWhat is your balance? *What is your monthly contribution? *Do you contribute to non-retirement savings? *YesNoWhat is your balance? *What is your monthly contribution? *HOUSING: Do you rent or own? *RentOwnAre you current on your payment? *YesNoWhat are the total monthly payments for your rent/mortgage? *CONSUMER DEBT: Do you have any vehicle Loans? *YesNoAre you current on your payments? *YesNoWhat 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? *NextWhat primary issue should we focus on during your coaching session? *BudgetingReal EstateDealing With CollectorsWealth Building/InvestingDebt EliminationOtherIf 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? *YesNoIf so, who, for what reason, and for how long? *NextReligious Faith *Christianity (Protestant)Christianity (Catholicism)IslamHinduismAgnosticismBuddhismAtheismSikhismSeventh-Day AdventistsLatter Day SaintJudaismProtestant Denomination *BaptistNondenominationalMethodistPentecostalLutheranPresbyterianRestorationistEpiscopalian / AnglicanCongegationalistAdventistAnabaptistOther EvangelicalOther ReformedPietistQuakerUnsureHave you accepted Jesus as your Lord and Savior? *YesNo UnsurePresent church affiliation or name of church you attend *Please tell me about that... *NextLegal Issues *NoYes, previously or currentlyCharges *Please explain. *Serving Probation? *YesNoNextEducation Level *No High SchoolSome High SchoolHigh SchoolSome Higher EdAssociates DegreeBachelors DegreeMasters DegreeDoctoral DegreeHigher Ed - School Name *Graduation Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are / Were you a service member? *Yes, currentlyYes, previouslyNoDate of enlistment *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of discharge *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Type of Discharge *General DischargeHonorable DischargeBad ConductDishonorable DischargeOther Than Honorable (OTH) DischargeWhat Branch? *ArmyNavyAir ForceMarinesCost GuardSpace ForcesOtherWhat Rank? *NextAre you satisfied with your present occupation? *YesNoWhat and with whom is your current occupation? *When did you start working with your current employer? *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you satisfied with your present income? *YesNoNextIs 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 * = CommentSubmit