Financial Literacy & Education Intake Form
Please complete this intake form to help us understand your needs and tailor our financial education services.
Client/Student Information
Tell us about yourself so we can better serve you.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Email
Phone Call
Text Message
Are you a student Are you completing this intake for yourself or for a student/child?
Myself
Child/Student
Service Selection
Select the services you are interested in.
Which services are you interested in? (Select all that apply)
Budgeting Support
Credit Education
Financial Literacy Topics
Math Tutoring
Other
Financial Snapshot
Help us understand your current financial situation.
What is your current monthly income? (Approximate)
What are your total monthly expenses? (Approximate)
Do you currently have any savings?
Yes
No
Do you have any outstanding debts (e.g., loans, credit cards)?
Yes
No
If yes, please describe your debts (type and approximate amount):
What are your biggest financial focus areas right now?
Budgeting
Saving
Investing
Debt Management
Retirement Planning
Tax Planning
Credit Score Improvement
Other
Please explain your other financial focus areas:
Budgeting Support
(Shown if 'Budgeting Support' is selected above)
What are your budgeting goals?
Create a budget
Stick to a budget
Reduce expenses
Increase savings
Pay off debt
Track spending
Plan for emergencies
Other
Other
What challenges do you face with budgeting?
Have you ever used a budget before?
Yes
No
Please describe your short term and long term financial goals
Credit Education
(Shown if 'Credit Education' is selected above)
What would you like to learn about credit?
Understanding credit scores
How to build credit
How to repair credit
Responsible credit use
Other
What best describes your credit situation?
Late payments
Collections
High credit card balances
No credit
Student loans
Auto loan
Other
Do you have any specific credit concerns or questions?
Financial Literacy Topics
(Shown if 'Financial Literacy Topics' is selected above)
Which financial literacy topics are you interested in?
Budgeting Fundamentals
Understanding Paycheck and Taxes
Budgeting Debt Pay Off Strategies
Credit Basics
Business Basics
Other
Please share any other financial topics you are interested in:
Math Tutoring
(Shown if 'Math Tutoring' is selected above)
Which grade level is tutoring needed for?
Elementary
Middle School
High School
College
Other
Which math topics do you need help with?
Basic arithmetic
Algebra
Geometry
Trigonometry
Calculus
Statistics
Accounting
Finance
Other
Other
Please describe your math tutoring needs:
Goals
Let us know your short-term and long-term financial goals.
Scheduling and Preferences
Tell us your availability and preferences.
Preferred days for sessions
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred time of day
Morning
Afternoon
Evening
How would you prefer to meet?
In-person
Virtual/Online
No preference
Acknowledgement & Signature
Please acknowledge and sign below.
Signature
Submit Intake Form
Submit Intake Form
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