Client Credit Repair Intake

Credit Repair Client Intake Form

Please provide detailed information to help us accurately assess your credit situation and begin the repair process.
Full Name*

First NameLast Name
Current Residential Address To Receive Mail*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Date Of Birth*

MonthDayYear
Date
Select Your Service Package*
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Basic Credit Repair
Entry Level package for individuals seeking a clean credit foundation. -3 rounds of disputes -Late payments, collections, charge-offs, inquiries -Monthly tracking & update reports -Email/Text support This package is perfect for clients with minor to moderate negative items

$475.00 Quantity



Elevated Credit Repair
Our premium service for more aggressive credit rebuilding. Includes: -Everything in Basic -Escalated Re-Disputes -4 Months of credit repair This package is ideal for clients preparing for homeownership

$675.00 Quantity



BankFresh
A complete ChexSystems & EWS (Early Warning System) restoration service for blocked or flagged banking records Includes: -Full review of reports -Written dispute strategy -Help opening new checking accounts This package is great for those denied bank accounts or flagged a high-risk

$225.00 Quantity



Total

$0.00
What is your primary goal for credit repair?*

Increase Credit ScoreRemove Specific Negative Items (e.g., collections, late payments)Prepare for a major purchase (e.g., home, car)Lower interest Rates
Have you obtained copies of your credit reports from the three major bureaus (Experian, Equifax, TransUnion)?*

Yes, I have all three reports ready to share.I have some reports, but not all three.No, I have not obtained them yet.
On a scale of 1 to 10, how urgent is your need for credit repair?*

1

2

3

4

5

6

7

8

9

10

1 is Not Urgent , 10 is Extremely Urgent
Please list any specific accounts you believe contain errors or should be disputed (e.g., Account Name, Account Number, Reason for Dispute).*

Type a question

Rows	Strongly Disagree	Diasgree	Neutral	Agree	StronglyAgree
I understand the factors that affect my credit score.
I consistently pay all my bills on time.
I am aware of my current debt-to-income ratio.
I know how to effectively dispute items on my credit report.

Upload Payment Confirmation (Zelle Payment: 240-413-3803 Shakeila S) (Chime: $KeyPlace)*

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Credit Repair Client Intake Form