Financial Wellness Client Intake Form

How did you hear about us?

Other (please specify)

Are you interested in:(Required)

Student Loan Counseling

Budget and Credit Counseling

Housing Counseling

Biographic & Demographic Info

Head of Household Full Name(Required)

First Last

Partner/Spouse Name (If Applicable)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County

Email(Required)

Date of Birth

Cell Phone Number

Alternate Phone Number

Do we have permission to text message with appt. reminders or other information?

Yes

Preferred Contact Method:

Cell Phone

Alternate Phone

Marital Status

Head of Household Race

American Indian/Alaskan Native

Asian

African-American

Native Hawaiian/Pacific Islander

White

Biracial/Multiracial

Prefer not to identify

Other

Partner/Spouse Race (if applicable):

American Indian/Alaskan Native

Asian

African-American

Native Hawaiian/Pacific Islander

White

Biracial/Multiracial

Prefer not to identify

Other

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?

Yes

Prefer not to identify

Are you disabled?

Yes

Prefer not to identify

What is your highest level of completed education?

Household 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

If an interpreter is desired, what kind of interpretation do you need?

Employment Information

Name of Employer

Employment Status

Other (please specify)

How long have you been employed here?

Do you have secondary employment?

Yes

Name of Second Employer

Partner/Spouse Employment Status

Name of Partner/Spouse Employer

Other (please specify)

Budgeting and Finances

Current Housing Status

Renting/Leasing

Paying Mortgage

If you are currently renting, please identify your rental status (check all that apply)

I pay full rent

I split rent

If you are currently renting, how long have you been renting?

Do you receive housing assistance subsidies?

Yes

I am seeking assistance to (check all that apply):

Buy a Home

Get Credit and Budget Counseling

Improve my Credit

Get out of Debt

How often do you receive income?

Bi-Weekly

Monthly

Weekly

Other

Salary/Wage Earnings

Expenses/Bills

Rent/Mortgage

Car Payment

Car Insurance

Credit Cards

Child Care

Medical Payments

Transportation

Water

Electricity

Gas (Utilities)

Cable/Streaming Service

Cell Phone

Food - Groceries

Food - Dining Out

Student Loan Payments

Tithing/Charitable Donations

Is there anything else you want to share about your financial situation?

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

Date

Signature

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

Horizons Family Services

819 5th St SE
PO Box 667
Cedar Rapids, IA 52406-0667

Phone:
319-398-3943
877-653-3123

Fax:
319-398-3577
877-453-2775