Financial Wellness Client Intake Form

Financial Wellness Client Intake Form

Biographic & Demographic Info

First
Last
First
Last
Address
Address
Street Address
Street Address Line 2
City
State/Province
Zip/Postal
Do we have permission to text message with appt. reminders or other information?
Preferred Contact Method:
Marital Status
Head of Household Race
Partner/Spouse Race (if applicable):
Head of Household Ethnicity
Partner/Spouse Ethnicity
Do you want an interpreter for services?

Employment Information

Housing Status and Housing Goals

If you are currently renting, please identify your rental status (check all that apply)
If you own your property, do you have a mortgage?
Is your mortgage current or delinquent?
I am seeking assistance to (check all that apply):

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

Statement_of_Counseling_Page_1 Statement_of_Counseling_Page_2

Privacy Policy

Privacy_Policy

Fee Schedule

Fee_Schedule

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