Empowering Financial Freedom

What is the Financial Wellness Center?

We provide housing counseling and financial literacy programs to people in our community. Horizons’ goal is to improve individual financial capability, as well as raise the level of financial stability in the community.

Is the Financial Wellness Center for Me?

Through classes, seminars, and counseling, we help individuals and families with the following services:

Improving credit.
Managing a budget.
Getting out of debt.
Preparing to buy or stay in a home.

Connect with the Financial Wellness Center

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

Month

Day

Year

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

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

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

Statement of Counseling Services

Horizons Financial Health & Wellness Service Privacy Policy

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Date

Month

Day

Year

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.

Register for Classes

Courses Offered

Homebuyer Education Course $99
Money Management Course $30
Post Purchase Homeowner Education $50
Foreclosure Education FREE

The course fee is non-refundable.

Representative Payee Services

Payee Intake Form

To be eligible for the program, you must be required by the Social Security Administration to have a representative payee. If you meet this requirement, please complete the attached intake form, provide copies of the documents required, and return at your earliest convenience. Once all information is received, a Horizons representative will contact you to begin the process.

Horizons will schedule an appointment with the SSA to apply as your representative payee once we have received the following items:

Completed intake form
Copy of identification and Social Security card
Guardianship letters of appointment, if applicable
Rental lease and/or housing authority paperwork
Utility bills (gas, electric, water)
Pharmacy bills
Mobile phone provider
Cable/Internet provider
Renter’s insurance

If you cannot complete this form online for any reason, please contact Horizons at 319-398-3943.

Once Horizons has been approved as your representative payee, please update your billing address for the above items to:

c/o Horizons, A Family Service Alliance
P.O. Box 2904
Cedar Rapids, IA 52406

Please upload your identification and Social Security card.(Required)

Drop files here or

Max. file size: 100 MB.

All data is secured and encrypted to GPDU guidelines

Please upload all other relevant files as indicated above(Required)

Drop files here or

Max. file size: 100 MB.

All data is secured and encrypted to GPDU guidelines

Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Where were you born?(Required)

Mother's Maiden Name(Required)

Father's First Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Other Phone

Gender(Required)

Race(Required)

Ethnicity(Required)

Veteran(Required)

Yes

Marital Status(Required)

Single

Married

Divorced

Separated

Widowed

Highest education completed(Required)

Junior High

High School

College

Other

Benefit/Income Information

Type of Benefit(Required)

Supplemental Security Income

Social Security Disability Insurance

SSA

Other

Amount of Benefit

Disabling diagnosis(Required)

Are you employed?(Required)

Yes

Do you receive any other types of income?(Required)

Yes

Do you receive Supplemental Nutrition Assistance Program (SNAP) benefits?(Required)

Yes

Medicaid number

Medicare number

Case Manager Name

First Last

Case Manager phone

Case Manager Email

Do you have a Legal Guardian/Conservator?(Required)

Yes

Do you have a current Payee?(Required)

Yes

Are you currently on probation?(Required)

Yes

Name, address, and telephone for any health professionals you see regularly:

Select any of the following assets you have:

Real estate

Vehicle

Life insurance

Burial Funds

iAble account

Trust account

Savings bonds

Personal account

List any other assets you have.

I am authorizing Horizons, A Family Service Alliance to contact any or all of the people, businesses, or agencies listed in this application to verify or discuss any of the information contained in this application. I understand that I must provide the list of required information as part of this application. I understand that Horizons, A Family Service Alliance is not yet my payee, and will not be able to pay any of my bills or provide me funds until they are approved by the Social Security Administration to do so.

Date

Month

Day

Year

Signature(Required)

Calculators and Resources

Financial Wellness Center Calculators

It is our goal to provide you with as much information and as many tools as possible with which to make sound money management decisions. The links below will provide you with valuable knowledge to guide you in taking the steps to positively impact your financial future.

Debt Calculator

Savings Goals Calculator

Mortgage Payment Calculator

Lifetime Earnings Calculator

Budget Percent Calculator

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Helpful Resources

HUD – U.S. Department of Housing and Urban Development works to strengthen the housing market and end homelessness. Find information about home buying, rental assistance, housing discrimination and more.

Volunteer with the Financial Wellness Center

Make a positive impact on the lives of people in our community by helping them achieve and maintain financial freedom.

Volunteer Application

See How Your Donation Makes a Difference

See Success Stories

We bought a house!! We got it for $16,000 UNDER the asking price! So it was worth the wait instead of buying this past summer. I spent the past 3 days cleaning and painting the mobile home, getting it ready to sell. Thank you for coaching us for the past three years and helping keep us on track!

– January 11, 2022

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Empowering Financial Freedom

What is the Financial Wellness Center?

Is the Financial Wellness Center for Me?

Connect with the Financial Wellness Center

Financial Wellness Client Intake Form

Biographic & Demographic Info

Employment Information

Budgeting and Finances

Expenses/Bills

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

Register for Classes

Courses Offered

Representative Payee Services

Payee Intake Form

Benefit/Income Information

Calculators and Resources

Financial Wellness Center Calculators

Helpful Resources

Volunteer with the Financial Wellness Center

See How Your Donation Makes a Difference

Horizons Family Services