LIFEC Interest Form

Welcome to LIFEC: Long Island Financial Empowerment Center!

Thank you for your interest in receiving free, one-on-one financial counseling and coaching through the Long Island Financial Empowerment Center, a program of Choice for All and our community partners.

Our trained financial advocates are ready to work with you and your family by helping them:
- Build and improve credit
- Manage debt
- Ceate budgets and savings plans
- Access safe banking services
- Strengthen long-term financial stability
This brief form will help us understand your interests and connect you with the right support.

The form takes about 2–3 minutes to complete. At the end, you will be able to schedule your first appointment.

All services are confidential and free of charge.
Section 1: Best Contact Information
Your Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Please select your township*
Ethnicity (check all that apply

AsianBlack/African-AmericanCaucasian/WhiteLatino/aPrefer not to answerOther
Primary Language*
Preferred Method of Communication (Select One)*

PhoneE-MailEither
Preferred Time of day for Contact (Check One)*

MorningAfternoonEvening
What site will be using for LIFEC?*
All clients must schedule an appointment with one of financial advocates on Wednesdays or Fridays. Please select from one of the following appointments. *
Financial Goals & Services

This questionnaire is designed to help us better understand your financial goals so we can provide the most relevant support or referrals. Please answer as openly as you feel comfortable. All responses are confidential.
What financial goals would you most like help with? Select up to three options.

Improving my creditReducing debtCreating a budgetStarting to save moneyOpening a bank accountIncreasing incomePlanning for a major expensesOther
When would you like to see progress on these goals?

Within the next 3 monthsWithin 6 monthsWithin 1 yearLong-term planning
Credit & Credit Building

Establish or build creditImprove my credit scoreReview or dispute items on my credit report
Budgeting & Money Management

Create a personal or household budgetManage my money more effectivelyPlan for future financial goals
Banking & Financial Access

Open a safe and affordable bank accountGet identification needed to open an account
Debt & Financial Challenges

Pay down debtManage debt collectors or collectionsUnderstand options related to bankruptcy
Saving & Financial Stability

Start saving moneyCreate a savings planLearn about long-term financial planning
Other Support

Identity theft concernsBenefits screening/financial resourcesHousing concerns (foreclourse or evictions)
How do you see your financial future? What is a goal you would like to want on or anything you want to share?
Should be Empty:

Section 1: Best Contact Information

Financial Goals & Services