Financial Strategy & Protection Prequalification Form
Thank you for your interest in a Financial Strategy. I am providing this service as a licensed life insurance agent. I know - life insurance sounds terribly boring, and yet, these tools can be the foundations of building intergenerational wealth if used correctly. You will learn about this and more in a 2-part Financial Strategy process that goes over six areas specific to your situation: cash flow, debt management, emergency fund, retirement & future planning, asset accumulation and estate preservation. Please take your time filling out the form to see if you are a candidate for a complimentary strategy session at this time. You will receive an email response within 24-48 hours of submitting the form.
Basic Information
Full Name
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First Name
Middle Name
Last Name
Email Address
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example@example.com
Phone Number (only used to communicate a last-minute scheduling change)
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Please enter a valid phone number.
Format: (000) 000-0000.
Country of Residence (Please note we can only serve US & Canadian residents at this time)
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United States
Canada
Current Financial Snapshot
Are you currently earning income?
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Yes - stable income
Yes - variable income
No
Current Annual Household Income
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Above $75,000
Below $75,000
Are you in a partnership or married?
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Not in a partnership
Yes, not married
Yes, married, and my partner would be involved in financial decisions
Do you have children and what are their ages?
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Yes, dependents
Yes, but they're out of the house
Not yet but planning to
Do you have retirement savings?
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Yes, I know what I need to retire and I'm on track.
Yes, I have a 401K or Roth and contribute a bit. I don't know if it's performing like I need it to to actually retire.
Not at all and I need a plan to know how to prepare for retirement.
Awareness & Context
How would you rate your current financial literacy?
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Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
What are your biggest financial concerns right now?
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What are your financial assets at this time?
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What are your top 3–5 financial goals over the next 1–5 years that you'd love to achieve with financial ease?
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What do you imagine is currently holding you back from your financial goals and dreams, if anything?
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The 6 Foundational Principles of Money:
In my financial practice, I focus on six pillars of financial independence: cash flow, debt, emergency fund, proper protection, asset accumulation, and legacy. When checking the boxes just know that there are no "right" or "wrong" answers. I use this intake as a tool to better support you on your journey into financial wellness, security and independence.
Cash Flow
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I have a current stream of income
I know my total monthly expenses
I know which categories I am spending money in
I know my annual net (after taxes) income
I'm currently putting money into a savings account
All of my incoming money has a job that I assign it
Other
Debt
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I have up to $10,000 in debt
I have $10,000 - $25,000 in debt
I have $25,000 - $50,000 in debt
I have $50,000+ in debt
I have a mortgage, car loan and/or student loans
I have consolidated my debt
I'm working to pay off my debts
Other
Emergency Fund
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I have an emergency fund of at least 3-6 months
I have an emergency fund of about a month's worth of expenses
I don't know what that is
I'm currently building an emergency fund
I'd like to start building an emergency fund
Other
Proper Protection
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I feel like myself and/or family would be financially stable if something emergent, unexpected and/or disabling happened to me (or primary income earner)
I feel like myself and/or family would NOT be financially stable if something emergent, unexpected and/or disabling happened to me (or primary income earner)
I worry about providing financial stability if something emergent, unexpected and/or disabling happened to me (or primary income earner)
I want to know of ways that I can create financial stability for myself and/or my family
I have a Life Insurance policy & I wonder if it's enough coverage
I have a Life Insurance policy & I'm pretty confident it's enough coverage
I would love to build into a policy with the option of 'living benefits' in case I get sick while I'm alive
Asset Accumulation & Savings
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I have a High Interest Savings Account (HISA) working for me
I have investment accounts making me passive income
I have assets making me passive income
I'm interested in HISAs, investment accounts and/or assets to make me passive income
I have a Retirement Saving Plan
Other
Generational Wealth
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I want to pass wealth onto my family or community when I pass
I want to build intergenerational wealth for my family
I have a Will
I have a Trust
I have a Beneficiary for my wealth
I don't want the government to take my money or tax it heavily!
Other
Readiness & Capacity
How soon do you want to strengthen or improve your financial situation & growth?
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Immediately
Within the next 3 months
3–6 months
No specific timeline
Are you ready to take action by implementing a strategy within the next 30–60 days if the strategy aligns with your goals?
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Yes, I am ready to move forward
Possibly, depending on what I learn
No, I am just exploring options
What is a realistic monthly contribution you can make toward your financial goals? (I'm not talking about coaching, I'm talking about you investing your own money into financial vehicles that protect and accumulate wealth.)
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Under $100
$100–$300
$300–$700
$700+
Not sure yet
Are you open to receiving professional guidance and a personalized, structured financial strategy?
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Absolutely
Possibly
Not at this time
There is no sitting fee for the financial strategy. If you receive a complimentary financial strategy and we help/empower you, would you be willing to reciprocate by referring 3-5 people to me?
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Yes
No
Final Step
How did you hear about this opportunity/me?
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This is a 2-part process. Do you commit to showing up prepared, with your partner if applicable, to both appointments?
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Yes
No
Do you commit to showing up for your scheduled appointments or rescheduling within 24-48 hours to respect everyone's time?
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Yes
I often cancel my commitments
Acknowledgement
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I understand that: This is an application for a Financial Strategy & Protection session. Not all applicants will be invited to schedule a full strategy session. Based on my responses, I will receive next steps via email. If it is a fit, I will be invited to book a session.
Submit Application
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