Financial Survey Financial Counseling and Coaching Survey Financial Counseling and Coaching Survey Name Email Phone Preferred Method of Contacting Phone Email 1. Do you currently have a personal budget, spending plan, or financial plan? Yes No 2. How confident are you in your ability to achieve a financial goal you set for yourself today? Not at all confident Somewhat confident Very confident 3. If you had an unexpected expense or someone in your family lost a job, got sick or had another emergency, how confident are you that your family could come up with money to make ends meet within a month? Not at all confident Somewhat confident Very confident 4. Do you currently have an automatic deposit or electronic transfer set up to put money away for a future use (such as savings)? Yes No 5. Over the past month, would you say your family’s spending on living expenses was less than its total income? Yes No 6. In the last 2 months, have you been charged a late fee on a loan or bill? Yes No Financial Goals: Check all that apply Improving Credit Improve Money Management Home Ownership Pay down debt Financial Security Education Large Purchase Home Rental Retirement Savings Learn more about investing Decide what is most important Deal with student loans Other Time Zone Eastern Central Mountain Pacific Preferred Communication Time frame (click all that apply) Morning Afternoon Evening Any Weekday Weekend Do you have a military affiliation? Active Duty Veteran Military Spouse Military Retiree Reserve/National Guard Military Dependent Are you looking for individual or couple's financial counseling? Individual Will meet as a couple Please describe why you are interested speaking with a financial counselor. Check so we know you are human. If you are human, leave this field blank. Submit