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Personal Information
Name
*
First Name
Last Name
Do you have a preferred name?
Date of birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
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1989
1988
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1986
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1984
1983
1982
1981
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1976
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1974
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1972
1971
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1969
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1945
1944
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1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Cell phone number
*
-
Area Code
Phone Number
Preferred email
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your preferred method of contact?
*
Phone
Email
What is your preferred method for a meeting?
*
Phone call
Virtual Meeting (Zoom, Skype etc)
In Person
Any of the above is fine
What primary issue should we focus on during our Coaching Session?
*
Debt
Real Estate
Dealing with Collectors
Wealth Building/Investing
Debt Elimination
Ebay/Ecommerce Financial Planning
Other
Employment Status
Are you
*
Employed
Retired
Business Owner
Homemaker
Not currently employed, but looking
Annual gross income
*
Do you forsee a change in your income in the next 2 years? If so why?
Will you have a pension at retirement?
Please Select
Yes
No
I don't know
Are you collecting Social Security?
*
Yes
No
Social Security income
Monthly
Family Information
Are you
*
Married
Single
Divorced
Widowed
Spouse's name
*
First Name
Last Name
Do they have a preferred name?
Is your spouse
*
Employed
Retired
Business Owner
Homemaker
Not currently employed, but looking
Spouse's annual gross income
*
Do you forsee a change in there income in the next 2 years? If so why?
Will they have a pension at retirement?
Please Select
Yes
No
I don't know
Are they collecting Social Security?
*
Yes
No
Spouse's Social Security income
Monthly
How many children do you have?
*
How do you feel about saving for your child's education?
If you are currently saving for college: Where are you saving, how much per month and what is the current value?
Any other information you feel we should know related to your family?
Do you have a will?
*
Yes
No
When did you last update your will?
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Who was the attorney that you used?
Have any changes occurred since you last updated your will?
Financial Information
What are your two most important planning issues?
*
Saving for retirement
Saving for college
Protecting my family
Estate planning
Paying off debt
Other
What is the best financial decision / investment you ever made?
What is the worst financial decision / investment you ever made?
If you could pass along 1 financial lesson to your children what would it be?
Do you have a working monthly budget?
*
Yes
No
What is your estimated tax bracket?
Usually listed on last year tax return
Who does your taxes?
Yourself or Accountant's Name
Did you receive a tax refund last year?
*
Yes
No
How much was your refund?
Life Insurance
Do you currently have any life insurance?
Yes
No
I don't know
Policy 1 - Death Benefit
Policy 1 - Premium (Cost)
Annually or monthly
Policy 1 - Type
Please Select
Term
Whole Life
Universal Life
I don't know
Policy 2 - Death Benefit
Policy 2 - Premium (Cost)
Annually or monthly
Policy 2 - Type
Please Select
Term
Whole Life
Universal Life
I don't know
Do you feel you have adequate insurance protection to cover your family's needs if something were to happen to you?
Yes
No
Not sure
Household Assets and Liabilities
Checking account
Value
Savings account
Value
Any other non-retirement accounts
Value
Retirement Account Values
Do you have
IRA
Roth IRA
401k
403b
Other
IRAs
Value
How much are you saving to your IRA per month?
Monthly Contributions
Roth IRAs
Value
How much are you saving to your Roth IRA per month?
Monthly Contributions
401k
Value
How much are you saving to your 401k per pay?
Per Pay (%)
401k investment company name
403b
Value
How much are you saving to your 403b per pay?
Per Pay ($ or %)
Other
Value
How much are you saving to your Other per pay?
Per Pay ($ or %)
Debts
Do you have
Mortgage Debt
School Loans
Credit Card Debt
Car Loans
Other
Mortgage balance
Mortgage payment
Mortgage interest rate
Mortgage paid off date
Approximate value of your home
School Loan balance
School Loan payment
School Loan interest rate
Credit Card balances
Credit Card monthly payments
Credit Card interest rates
Auto Loan
Own
Lease
Auto Loan balance
Auto Loan payment
Monthly
What is your plan to eliminate these debts?
Please describe your past experience working with a Financial Coach/advisor. What did you like? Where did this person not meet your expectations? What do you expect from your financial advisor?
Any other information you feel we should know?
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