Client Information Sheet
Client Name
*
First Name
Last Name
Birth Date
*
/
Month
/
Day
Year
Date
Gender
*
Relationship Status:
*
Single
Married
Separated
Divorced
Widowed
Race/ Ethnicity:
*
Black
Hispanic or Latino / Latina
Native American
White
Hawaiian/ Pacific Islander
Employment Status
*
Full-Time
Part -Time
Seasonal
Retired
Unemployed
Student
Occupation
*
Payment Frequency
*
Weekly
Bi-Weekly
Monthly
Semi-Monthly
Veterans/ Active Duty/ Reserves
*
yes
no
If yes, in which branch did you serve?
*
(Type N/A if it does not apply)
Contact Information:
Local Street Address
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Number of child dependents (under 18):
*
Number of adult dependents:
*
Financial Information:
Household Monthly Take-Home Pre-Tax Pay( Gross Income):
*
indicate whether per week, bi-weekly, month, or year
After Tax-Pay (Net Income):
*
indicate whether per week, bi-weekly, month, or year
Housing Status
*
Buying
Renting
Room & Board
Shelter
Current rent / house payment?
*
/Month
Please indicate the area(s) you are most concerned with today (Check all that apply):
*
Money Management / Budgeting
Credit Report Questions
Behind in Monthly Payments
Student Loan Questions
Medical Expenses
Repayment of Loans
Start Building Credit
Unexpected Crisis (Financial)
Rent / Mortgage Questions
Pay Down Debt
Unemployment
Set up Savings Plans
Please indicate how you heard about us
*
(word of mouth, social media, online search, etc.)
What questions would you like to have answered during your session?
*
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