FINANCIAL RESET BLUEPRINT
Client Financial Intake Form
Please complete this intake form to help us understand your current financial situation and goals.
SECTION 1: CLIENT INFORMATION
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Marital Status
Single
Married
Common-law
Separated/Divorced
Widowed
Prefer not to say
Number of Dependents
City / Province
Primary Financial Concern
What does financial stability look like to you?
SECTION 2: INCOME OVERVIEW
Please list all monthly income sources (after taxes).
Monthly Income Sources
*
Rows
Net Monthly Amount ($)
Employment Income
Self-Employment
Side Income
Child Support
Government Benefits
Other
Total Net Monthly Income ($)
*
Is your income:
*
Stable
Commission-based
Seasonal
Irregular
FIXED MONTHLY EXPENSES
(These are consistent every month)
Fixed Monthly Expenses
Rows
Monthly Amount ($)
Rent / Mortgage
Property Tax
Utilities
Internet
Phone
Insurance (home/tenant)
Auto Insurance
Car Payment
Childcare
Subscriptions
Other Fixed Expenses
Total Fixed Expenses ($)
*
VARIABLE SPENDING (Average Monthly)
Review your last 3 months of bank statements and estimate averages.
Variable Spending
Rows
Monthly Average ($)
Groceries
Dining Out
Gas
Shopping
Entertainment
Personal Care
Kids Activities
Miscellaneous
Estimated Total Variable Spending ($)
*
DEBT SUMMARY
Debt Summary
Rows
Balance ($)
Minimum Payment ($)
Interest Rate (%)
Credit Card 1
Credit Card 2
Line of Credit
Car Loan
Student Loan
Installment
Other
Total Debt Owed ($)
*
Total Monthly Debt Payments ($)
*
SAVINGS & ASSETS
Savings & Assets
Rows
Current Balance ($)
Chequing
Savings
TFSA
RRSP
Emergency Fund
Investments
Cach
Do you currently have:
*
Emergency Fund (3+ months)
No Emergency Fund
Savings but inconsistent
FINANCIAL BEHAVIOUR & HABITS
Do you currently follow a budget?
*
Yes
No
Tried before but failed
What triggers overspending?
*
Stress
Convenience
Emotional spending
Lack of planning
Social pressure
Other (please specify)
If Other, please specify
*
On a scale of 1–10, how in control do you feel of your finances?
*
Not in control
1
2
3
4
5
6
7
8
9
Completely in control
10
1 is Not in control, 10 is Completely in control
What is your biggest financial fear?
*
What is your biggest financial goal in the next 12 months?
*
CONSENT & DISCLOSURE
I understand that this program provides financial organization, budgeting guidance, and accountability support. It does not provide licensed financial, tax, or investment advice.
I acknowledge and agree.
*
I acknowledge and agree.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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