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Financial Coaching Intake Sheet

Hello! Thank you for reaching out to us for financial coaching. We understand it’s not easy to ask for help, however we feel it is always better to ask for help, than suffer in silence. Please fill out the following information so we can tailor a program that fits your needs.

First Name: Last Name: Email: Phone Number: 1) What is the major reason/reasons you reached out to FACTS for financial counseling? 2) Do you regularly use a monthly budget to plan your financial life? If no, have you ever used one and do you know how to create one? 3) Are you currently saving for retirement? If so, what vehicle are you currently using? (IRA, 401K, 403B, etc) 4) What are your financial goals and what do you hope to get out of this financial coaching? 5) Are you currently receiving any of the 6 welfare programs listed below? If so, please indicate which one(s) and provide proof of your eligibility along with this completed form. • Supplemental Nutrition Assistance Programs (SNAP or Food Stamps)• Temporary Assistance for Needy Families (TANF)• Supplemental Security Income (SSI)• Housing assistance (Section 8)• Earned Income Tax Credit• Medicaid• N/A

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If you have not received any of the assistance listed above, indicate N/A and proceed with submission.

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