Credit Repair Form
New Client Intake
Name
*
First Name
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
What's your credit score?
*
Below 500
551 - 600
601-650
Above 650
I don't know
Do you have any late payments in the last 12 months?
*
Yes
No
Do you need funding?
*
Yes
No
If you need funding, how much?
*
$5,000 - $15,000
$15,000 - $45,000
$45,000 and more
How do you feel when you apply for loans or credit?
*
Confident I'll get approved
Afraid/Embarrassed for getting denied
Neutral
Which credit monitoring services do you have?
*
Please Select
Identity IQ
My Freescore
Smart Credit
None
Why do you want to improve your credit?
*
Access to money
Better interest rates
A new home/apartment
Capital for business
Buy new/used vehicle
Other
Have you attempted credit repair in the past?
*
Yes
No
Are you involved in any legal matter(s) recently? (litigation, lawsuit, etc.)
*
Yes
No
On a scale of 1-5 ( 1 being low in priority & 5 being top priority), how committed are you to achieve financial goals?
*
1 (I'm just curious)
2 (Interested but likely won't take action)
3 (I'm 50/50)
4 (I'm interested but I just don't know what to do)
5 (I'm ready to invest)
How much are you ready to invest in the process?
*
0 - $300
$300 - $600
$600 - $900
Whatever it takes!
How did you hear about us?
*
Facebook
Instagram
Search Engine (google etc.)
Youtube
Referral
If you were referred by someone, tell us who.
What questions do you have for us?
*
Submit
Should be Empty: