RCDC - Financial Coaching Intake

Please fill in your details.

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Race

White

Black or African American

Asian

American Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander

Alaskan Native and White

African American and White

Asian and White

American Indian or Alaskan Native and African American

Other Multi Racial Demographic

Marital Status

Single
Married
Divorced
Widow(er)
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Spouse Name

Number of adults in your household over the age of 18?

Number of children in your household under the age of 18?

What is your yearly household income?

Less than $15,000

$15,000-$24,999

$25,000-$34,999

$35,000-$44,999

$45,000-$49,999

$50,000-$65,999

$65,000+

Do you rent or own?

Rent

Own

What day of the week are you available to meet with a Financial Coach

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Best time to meet with a Financial Coach?

Morning
Afternoon
Evening
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Rate the following statements and questions. 1=Not at all; 5=Extremely

I am comfortable with checking my credit

1 Not at all

2

3

4

5 Extremely

I am comfortable with completing the employee W-4 form.

1 Not at all

2

3

4

5 Extremely

I am comfortable with setting up a budget.

1 Not at all

2

3

4

5 Extremely

I am satisfied with my investments.

1 Not at all

2

3

4

5 Extremely

I am satisfied with my credit score.

1 Not at all

2

3

4

5 Extremely

I am satisfied with my 3-6 month emergency cash reserve.

1 Not at all

2

3

4

5 Extremely

I am satisfied with my retirement savings

1 Not at all

2

3

4

5 Extremely

How interested in changing careers/jobs?

1 Not at all

2

3

4

5 Extremely

How interested are you in starting a business?

1 Not at all

2

3

4

5 Extremely

How interested are you in purchasing a home?

1 Not at all

2

3

4

5 Extremely

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.