Board of Trustees

Steve Pace

Shuttleworth & Ingersoll, PLC

Board Chair

John Bickel

Shuttleworth & Ingersoll, PLC

Board Chair

Kathy Eno

Shuttleworth & Ingersoll, PLC

Board Chair

Nancy Evans

Shuttleworth & Ingersoll, PLC

Board Chair

Deborah Lindberg-Gertsen

Shuttleworth & Ingersoll, PLC

Board Chair

Joel Schmidt

Shuttleworth & Ingersoll, PLC

Board Chair

Gary Streit

Shuttleworth & Ingersoll, PLC

Board Chair

Financial Wellness Client Intake Form
Financial Wellness Client Intake Form
How did you hear about us?
Other
Biographic & Demographic Info
Head of Household Full Name
First
Head of Household Full Name
Last
Partner/Spouse Name (If Applicable)
First
Partner/Spouse Name (If Applicable)
Last
Address
Address
Street Address
Street Address
Street Address Line 2
Street Address Line 2
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
County
Cell Phone Number
Alternate Phone Number
Do we have permission to text message with appt. reminders or other information?
Yes
No
Email
Date of Birth
Preferred Contact Method:
Cell Phone
Email
Alternate Phone
Marital Status
Single
Married
Divorced
Separated
Widow
Head of Household Race
American Indian/Alaskan Native
Asian
African-American
Native Hawaiian/Pacific Islander
White
Biracial/Multiracial
Prefer not to identify
OtherOther
Partner/Spouse Race (if applicable):
American Indian/Alaskan Native
Asian
African-American
Native Hawaiian/Pacific Islander
White
Biracial/Multiracial
Prefer not to identify
OtherOther
Head of Household Ethnicity
Hispanic
Non-Hispanic
Prefer not to identify
Partner/Spouse Ethnicity
Hispanic
Non-Hispanic
Prefer not to identify
Are you a veteran?
Are you disabled?
What is your highest level of completed education?
Household TypeHousehold Type
Total number of adults in your household
Total number of children in your household
Please list your household's primary languages.
Do you want an interpreter for services?
Yes
No
If an interpreter is desired, what kind of interpretation do you need?
Employment Information
Employment StatusEmployment Status
Name of Employer
How long have you been employed here?
Do you have secondary employement?
If yes, who is your secondary employer?
Partner/Spouse Employment StatusPartner/Spouse Employment Status
Name of Partner/Spouse Employer
Housing Status and Housing Goals
Current housing status
If you are currently renting, please identify your rental status (check all that apply)
I pay full rent
I receive a rent subsidy and/or live in public housing
I am a Section 8 recipient
I am facing eviction
I am delinquent with my rent and need assistance
I am delinquent with utilities and need assistance
If you are currently renting, how long have you been renting? (Total months)
If you own your property, do you have a mortgage?
Yes
No
Is your mortgage current or delinquent?
Current
Delinquent
Do you receive housing assistance subsidies?
If yes, please specify type of subsidy:
I am seeking assistance to (check all that apply):
Buy a home
Prevent foreclosure
Obtain rental housing
Increase housing affordability
Get credit and budget counseling
Transition from homelessness
Pre/Post Bankruptcy Counseling
OtherOther
Income and Average Monthly Expenses
Income (Please list all applicable income)
How often do you receive income?How often do you receive income?
Salary/Wage Earnings
Salary/Wage Earnings
Rental Income
Rental Income
Child support/Alimony
Child support/Alimony
Social Security
Social Security
Pension
Pension
Dependent SSI Income
Dependent SSI Income
Disability Income
Disability Income
Unemployment Income
Unemployment Income
Public Assistance Income
Public Assistance Income
Other
Other
Monthly Expenses (Please List All Applicable Expenses)
Rent/Mortgage
Car Payment
Car Insurance
Credit Cards
Child Care
Alimony/Child Support
School Tuition
Medical Payments
Transportation (i.e. gas, bus, ride-share)
Water
Electricity
Gas (Utilities)
Cable/Streaming Service
Cell Phone
Food-groceries
Food-dining out
Student Loan Payments
Tithing/Charitable Donations
Other
Assets (Please List All Applicable Assets)
Home
Vehicle
401k/Retirement
Recreational Vehicles
Checking Account(s)
Savings Account(s)
Rental Property(s)
Other
Is there anything else you want to share about your financial situation?
Horizons' Statement of Counseling Services, Privacy Policy, and Fee Schedule
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Board of Trustees

Steve Pace

John Bickel

Kathy Eno

Nancy Evans

Deborah Lindberg-Gertsen

Joel Schmidt

Gary Streit

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Financial Wellness Client Intake Form

Biographic & Demographic Info

Employment Information

Housing Status and Housing Goals

Income and Average Monthly Expenses

Income (Please list all applicable income)

Monthly Expenses (Please List All Applicable Expenses)

Assets (Please List All Applicable Assets)

Horizons' Statement of Counseling Services, Privacy Policy, and Fee Schedule

Statement of Counseling

Privacy Policy

Fee Schedule

By signing and dating below, I confirm that I have received a copy of Horizons' Statement of Counseling Services, Privacy Policy, and Fee Schedule.

Bankruptcy Education Disclosure

Bankruptcy Services Fee Policy

Bankruptcy Counseling Disclosure

Bankruptcy Services Fee Policy