Personal Financial Preparedness Form

1

Household Income* This field is required.

Less than $30k annually

Between $30k and $60k annually

Between $60k and $90k annually

Between $90k and 150k annually

More than $150k annually

2

Do you currently have an emergency fund?* This field is required.

YESNO

3

How many months of living expenses could your emergency fund cover?* This field is required.

< 1 Month

1-3 Months

4-6 Months

7-12 Months

12+ Months

4

Do you have a dedicated savings account for short-term goals (e.g., vacation, car repairs)?* This field is required.

YESNO

5

Do you contribute to retirement savings (e.g., 401(k), IRA, pension)?* This field is required.

Yes, consistently

Occasionally

No

6

What is your total retirement savings (approximate)?* This field is required.

$0

< $10k

$10,001 - $50,000

$50,001 - $250,000

> $250,000

7

How confident are you that your savings would support you in a long-term emergency (e.g., job loss, medical crisis)?* This field is required.

Not at all

Slightly

Somewhat

Very

Completely

8

Have you automated your savings (e.g., direct deposit or automatic transfers)?* This field is required.

YESNO

10

What is your total outstanding debt (excluding mortgage)?* This field is required.Credit Cards, Student Loans, Auto Loans, Personal Loans, Other

$0

< $5k

$5,001 - $20k

$20,001 - $50k

> $50k

12

Do you regularly carry a credit card balance from month to month?* This field is required.

YESNO

13

What is your average monthly debt payment (excluding mortgage)?* This field is required.

$0

< $250

$250 - $1,000

$1000 - $2,000

> $2,000

14

Do you know your current credit score?* This field is required.

YESNO

15

Have you ever missed a debt payment in the past 12 months?* This field is required.

YESNO

16

Are you actively working on a plan to reduce or eliminate your debt?* This field is required.

YESNO

17

Do you have a written monthly budget or spending plan?* This field is required.

YESNO

18

How often do you review your income and expenses?* This field is required.

Weekly

Monthly

Quarterly

Rarely/Never

19

Do you have any form of income protection (e.g., disability insurance, multiple income sources)?* This field is required.

YESNO

20

Have you created a financial plan for unexpected events (e.g., recession, family crisis, natural disaster)?* This field is required.

YESNO

21

Do you have a will, trust, or other estate planning documents in place?* This field is required.

YESNO

22

How financially confident do you feel overall?* This field is required.

Not at all confident

Slightly confident

Moderately confident

Very confident

Extremely confident

23

Please provide your email address if you'd like a free financial coaching consultation.If you don't - just leave this field blank,

example@example.com