B. Drake Agency Concierge Intake & Triage Form
Complete this form to help us understand your financial goals and needs for personalized guidance.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best time for a consultation
*
Morning
Afternoon
Evening
What is your primary financial goal for your family’s future?
*
Income Protection
Mortgage Protection
Retirement & Wealth Growth
Debt-Free Planning
Estate & Legacy Planning
Needs Analysis (Professional Audit)
Which best describes your current situation?
*
No current policy
Policy through work
Looking to supplement or replace
What is your primary focus?
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Pay off mortgage if I pass away
Disability coverage
Lower monthly cost
What is your main priority?
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Tax-efficient accumulation
Guaranteeing retirement income
Protecting savings from market volatility
What is your primary obstacle?
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High-interest debt management
Budgeting and cash flow
Long-term financial independence plan
Where are you currently in the process?
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DIY will or trust needs review
Unfunded trust
Just starting and undecided
On a scale of 1-5, how familiar are you with your current coverage or financial strategy?
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Not familiar
1
2
3
4
Very familiar
5
1 is Not familiar, 5 is Very familiar
What is your primary concern regarding your financial legacy?
*
Protecting assets from market loss
Ensuring my family's future is secure
Funding for my children's education
Ensuring my legal documents are properly structured
Other
Are you ready to schedule a formal consultation to discuss your personalized strategy?
*
Yes, book my appointment
No, I have questions—Request a Preliminary Review
Submit
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