CLIENT INTAKE (FINANCIAL ANALYSIS):
In order to provide customized and compliant service please fill out the following
How did you hear about us?
*
Please Select
Instagram
Facebook
Referral
Website
other
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
SIN
*
Were you born in Canada?
*
Please Select
Yes
No
If not, what Country were you born in?
Employer
*
Annual Income
*
Position
*
Employer Address
*
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Spouse Information
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Position
Employer
Annual Income
Employer Address
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Health Questions
Do you smoke?
*
Please Select
yes
no
Do you use any of the following (Check all that apply)
*
Vape
Marijuana
More than 12 alcoholic beverages per week
Other non prescription drugs
none
Have you seen a specialist or had any medical consultation in the last 5 years? Please give details
*
Doctors name and Address
*
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Financial Information
Monthly Household Discretionary Income (Income - Expenses)
*
Financial Goals - select anything that applies
*
Being debt free
Building retirement wealth
Buying a home
Children's education
Building up emergency savings
Travel funds
Legacy building for future generations
Other
Do you have dependents?
*
Yes
No
In our plans
Ages of dependents
Total Assets (home, cars, savings)
*
Do you have a mortgage?
*
Yes
No
In our plans
Amount of mortgage and Term
*
Total Liabilities (mortgage, credit card or line of credit debt etc)
*
Check off any investments/Insurance you have in place
*
TFSA
RRSP
RESP
Life Insurance
Unregistered Investments (crypto, savings etc)
Critical Illness and/or diability
If yes to life insurance, please indicate issuing insurer, coverage amount, and monthly premiums (not through employer)
*
Please upload drivers license
*
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