Client Intake Form

Client Intake Form for Credit Restoration Services
Name*

First NameLast Name
Email*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What Timezone are you in?*
Questionnaire
What are your financial goals?*
How soon are you trying to accomplish these goals?*
How quickly do you need your credit repaired?*

1-3 Months4-6 MonthsNo Specific Time, I Just Want It Done Right
Have you worked with another Credit Repair Company in the last 6 months?*

YesNo
If yes, when was this and what was your experience?
Do you have any ACTIVE bankruptcies?*

YesNo
If Yes, are they Dismissed ?
Have you ever been a victim of Identity Theft?*

YesNoNot Sure
Do you have any student loans?*

YesNo
If Yes, are they in Deferment ?
Do you have a job or stable income?*

YesNo
What are your expectations for this credit repair service?*

Increase Credit ScoreRemove Negative ItemsSettle DebtsPrepare For A Major PurchaseGeneral Financial Improvement
What major purchase are you trying to make?*
Are you currently in a financial situation that would prevent your from paying your bills in the next 6-9 months?*

YesNo
Are you comfortable with possibly waiting 6-9 months to complete this program? **(May be completed sooner )***

YesNo
Do you have the ability to make regular payments for credit-related costs (e.g., payments toward valid debts, monthly payment for this credit program)at a low rate?*

YesNo
Are you committed to following a budget and adjusting financial habits during this program?*

YesNoNot Sure,Would Need Guidance
Are you interested in earning additional income ?*

YesNo
What's your Credit Score?*
How did you hear about us?*

FacebookInstagramReferral
If Referral , by whom?
Schedule 1 On 1 Consultation - After Above Form Is Completed! If Form Is Not Completed, YOU WILL HAVE TO RESCHEDULE!

After Scheduled , Submit Form At Bottom of this Page!
*
Privacy Disclaimer

We value your privacy and are committed to protecting your personal information. All the information you provide in this form will be kept strictly confidential and will only be used to evaluate your eligibility for our credit repair services. Your data will never be sold or shared with third parties without your explicit consent, except as required by law. We implement appropriate measures to ensure the security of your information, protecting it against unauthorized access, alteration, or misuse.
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Client Intake Form for Credit Restoration Services

Questionnaire

Schedule 1 On 1 Consultation - After Above Form Is Completed! If Form Is Not Completed, YOU WILL HAVE TO RESCHEDULE!