Save First Financial Universal Application

General Application
Name

First NameLast Name
Email
Mobile Number
Format: (000) 000-0000.
How did you hear about us?
Corporate/Faith Partner Name
Community Partner Name
Please specify
Are you interested in Emergency Assistance?
Have you applied for assistance before?
Which Location Do You Work At?
Which Department Do You Work In?
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Demographics

Answering the demographic questions helps us connect you with clients who may have requested someone with a similar background or lived experience.
Household Type
Do you own or rent your housing?
Housing Details
How many people are in your household (including yourself)?
What primary language is spoken at home?
Other Language Name
Gender
Cultural Heritage
Cultural Heritage Details
Country of Origin (if other than US)
Are you a US Veteran?
Employment Status
Employment Status Details
Program Questions

At Save First Financial Wellness, we ask about income, expenses, and non-cash benefits (such as SNAP or TANF) to better understand your financial situation and provide support that fits your needs. This information helps us determine eligibility for scholarships and our sliding fee scale, which is available to individuals and families earning up to 250% of the Federal Poverty Guidelines. All information is kept confidential and used only to ensure fair, equitable access to our services. Our goal is to meet you where you are and make financial education and coaching accessible to everyone.
Please Give a Brief Description of Your Current Situation
What Bill(s) Do You Need Assistance With?
What Steps Have You Already Taken?
Are you interested in Financial Education?
Are you interested in Financial Coaching?
The following questions are to understand your financial situation and help you find the best coach for your current financial position and goals.
What goal(s) do you want to work on during coaching?

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Do you have any preferences on the type of coach you are matched with that we can try to accommodate? (i.e. gender, age etc.)
Coach Preference Details
Do you have a partner or spouse that will participate in coaching with you? If so, please add their name here.
Please check all of the boxes for days that you are generally available to meet with a coach. (Please note that availability of staff coaches are limited to weekdays during working hours, volunteer coaches are subject to personal availability and may include weekends).
Please provide details about the times you are available on the days you selected.

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Are you interested in receiving coaching remotely or in person?
Are there challenges making it hard to be financially stable?
State your entire household's income from the last 30 days (take home/net)
Please break down the amounts of your household's income from the last 30 days (take home/net) by source.

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Does anyone in your household receive any of these non-cash benefits?
Are you interested in applying for a Financial Coaching scholarship if you are deemed eligible?
Are you interested in Resource Navigation?
What resources are you interested in?
Are there any additional resources or services you would like assistance with?

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Is there anything else you would like us to know?
Consent for Services and Acknowledgment of Agreement. By selecting "Agree" below and choosing to participate in the Save First Program, I acknowledge that I am agreeing to engage in financial wellness services and will follow the outlined commitments, including attending scheduled meetings, actively participating in the service process, and communicating any necessary updates to my staff contact. I understand that, upon request, Save First Financial Wellness will provide me with a copy of the forms I have signed for my records. This acknowledgment is my formal acceptance of services, and I agree to the terms and conditions set forth by the Save First Program.
Please only click the Submit button below once, unless you are clicking it again after resolving a field error.
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General Application

Demographics

Program Questions