Intake Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
*
-
Month
-
Day
Year
Birthdate
Cell Number
*
Preferred
Home Number
Email
*
example@example.com
What brought you to Leverage Planners?
*
Please Select
Live Social Security/Retirement class
Live Medicare class
Live Dinner Seminar
Live Theater Seminar
Live Web Class
Recorded Web Course
TV Ad
Radio Ad
Web Ad
Mailer, Postcard
Mailer, Envelope Letter
King 5 New Day Interview
Friend Referral
Web Search
Phone Offer
F3 Pax
What is your preferred communication method for us to reach you?
*
Please Select
Email
Phone Call
Text
We take a Safety First approach for retirement planning. Is that what you want?
*
Yes
No
How else can we help you?
*
Which issues are your primary concerns?
*
Guaranteeing I don't lose my money
Guaranteeing I never run out of bill-paying income
Doubling or tripling my money if I need LTC
Wills, or Trust Estate plans
Eliminating fees & expenses
Reducing taxes in retirement
ALL of the ABOVE
Other
Additional Details on Concerns
Is there anything else you'd like us to know about you, your family, your life situation, and what you already know you really want for your life, so that we can prepare for you?
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