CREDIT REPAIR CLIENT INTAKE
$299 Service
CONTACT INFORMATION
Full legal name *
*
First Name
Last Name
Email address *
*
example@example.com
Phone number *
*
Format: (000) 000-0000.
State of residence *
*
Preferred communication: Email / Phone / Text
Best time to contact you
CREDIT PROFILE AND GOALS
Primary goal: Improve score / Correct errors / Prepare for financing / Other
Estimated credit score range (optional)
Credit bureaus showing errors: Experian / Equifax / TransUnion / Unsure
Which items concern you? Collections / Late payments / Inquiries / Identity theft / Other
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CREDIT REPAIR CLIENT INTAKE
$299 proposed service price | Confidential intake - no advance collection
Describe the errors or issues you want reviewed
Have you previously disputed any inaccurate items? Yes / No
Yes
No
Are you working with another credit repair provider? Yes / No
Yes
No
What outcome are you hoping for?
CONSULTATION AND ACKNOWLEDGMENTS
Preferred consultation date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred consultation method: Phone / Video
Yes
No
I understand accurate negative information cannot be guaranteed removed: Yes / No *
*
Yes
No
I understand this intake is not a contract or payment authorization: Yes / No *
*
Electronic signature (type full name) *
*
Date *
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
[BUSINESS NAME] | Client intake template - customize before publishing
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CREDIT REPAIR CLIENT INTAKE
$299 proposed service price | Confidential intake - no advance collection
IMPORTANT INFORMATION
Proposed service price: $299. Do not collect an advance credit repair payment. Before service begins, supply the legally required written disclosures, compliant contract, cancellation notice, and payment timing reviewed for the business jurisdiction. Do not request SSNs, identity documents, or credit-monitoring passwords in this general intake.
[BUSINESS NAME] | Client intake template - customize before publishing
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