Client Intake & Credit Profile Questionnaire

Credit Education Interest Form
Client Identification
Full Name

First NameLast Name
DOB

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Method of Contact
Identification

Used solely for identification purposes
Government Issued Photo ID

Cancelof
Proof of Address (Utility bill / Lease)

Cancelof
Social Security Card

Cancelof
Credit Profile Overview
Current Credit Score Range
Negative Accounts
Credit Goals
What are your primary credit goals?
Target timeline
Financial Snapshot
Employment Status
Monthly Income Range
Monthly Debt Obligations
Previous Dispute Activity
Have you previously disputed items on your credit report within the past 30 days?
Have you worked with another credit repair company within the past 30 days?
Have you contacted creditors directly regarding disputes within the past 30 days?
Do you have TransUnion, Equifax, Experian accounts? If so, please add login information in the box below.
Compliance & Disclosures
Serenity Consulting Group provides credit consulting and educational services. We do not guarantee specific results. Outcomes depend on the accuracy of information reported and responses from credit bureaus and furnishers.
Acknowledgement
Authorization
I certify that the information provided in this intake form is accurate and complete to the best of my knowledge. I authorize Serenity Consulting Group to review my credit profile and provide consulting services.
Signature
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Credit Education Interest Form

Client Identification

Identification

Credit Profile Overview

Credit Goals

Financial Snapshot

Previous Dispute Activity

Compliance & Disclosures

Authorization