Customer Information:
Your Name
First Name
Last Name
Spouse/Partner Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
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Cuba
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Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
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Egypt
El Salvador
Equatorial Guinea
Eritrea
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
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The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
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Nepal
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Netherlands Antilles
New Caledonia
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Nigeria
Niue
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Northern Mariana
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Palestine
Panama
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Paraguay
Peru
Philippines
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
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Uruguay
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Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Contact Number
-
Area Code
Phone Number
E-mail
Spouse/Partner E-mail
example@example.com
How many children do you have and what are their ages? Type "none" if no children
To begin, please choose the lifestyle or situation that best applies to you:
I'm an individual who does not share finances with anyone
I'm in a relationship (cohabitating, living together, married, engaged, etc)
Your occupation
Spouse/Partner occupation
Your date of birth
Spouse/Partner date of birth (if applicable)
How did you find out about Family Money Coaching?
Describe how you manage money currently. No system, Everything set up on auto pay, Don't pay attention, Track every thing, Uses a spreadsheet, Uses credit card for everything, etc. No right or wrong answers here - the more detail you provide the better!
Who do you bank with?
How many checking accounts do you have?
1
2
3+
If you said more than one checking account, what is the purpose of each account?
i.e. One is for bills and the other spending or one is just an oldaccount.
If you've tried budgeting before, please describe what your budgeting approach looked like
How CONFIDENT are you with what you're doing with your money? (1 is "not at all" and 5 is "extremely")
How STRESSED are you in regard to money? (1 is "not at all" and 5 is "extremely")
Where do you think you stand financially right now?
How would you react if, during your Discovery session, I told you that you're overspending compared to your income and that lifestyle changes need to be made?
How would you react if, during your Discovery session, I told you there's plenty of money to accomplish your goals, but it requires changes to your money management system, behaviors and mindset?
SPOUSE'S ANSWER. How STRESSED are you in regard to money? (1 is "not at all" and 5 is "extremely")
SPOUSE'S ANSWER. How CONFIDENT are you with what you're doing with your money? (1 is "not at all" and 5 is "extremely") (if applicable)
Describe how you split the responsibilities of managing money currently? i.e. Who pays the bills, who transfers the money, etc. It's very normal for this to be one person's job.
What do you hope to gain from this session?
Both respond
When you get inspired by something, what does it take for you to implement it?
Both respond
Are you the type of person who:
Implements ideas immediately
Takes lots of notes but then sticks them in a drawer
Thinks about things for a few weeks before making changes
My reason(s) for wanting to get control of my money is so I can (check all that apply):
Have more money
Be less stressed
Have more confidence
Stop working
Travel more
Buy more things
Spend more time doing the things I enjoy
Raise money for Adoption
Raise money for Fertility
What is your primary financial goal?
The Discovery session is just the beginning. It's meant to get the ball rolling in the right direction. Would you like information on how coaching can continue after the Discovery session?
Yes
No
Thank you for completing this survey!
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