Financial Literacy Coaching

1Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Preferred Contact Method

2Income Information

Primary Job (Monthly After Tax) *

Secondary Income (Monthly)

Other Income Sources (Monthly)

How stable is your income?

Total Monthly Income: $0

3Monthly Expenses

💡 All expense fields auto-calculate your totals below

Rent/Mortgage

Utilities

Phone

Car Payment

Insurance (Car/Health)

Groceries

Gas/Transportation

Dining Out

Entertainment

Total Monthly Expenses: $0

Available Cash Flow: $0

4Current Debt Information

💡 Debt amounts and payments auto-calculate below as you enter them

List all your debts below. If you have more than 10 debts, use the "Additional Debts" box.

Creditor/Account	Current Balance	Minimum Payment	Status	Interest Rate (%)

Additional Debts (if you have more than 10):

List any additional debts with details:

Total Debt Amount: $0

Total Minimum Payments: $0

Cash Flow After Debt Payments: $0

5Financial Behaviors & Goals

What usually causes you to overspend? (Check all that apply)

Stress/Emotions Social Situations Boredom Sales/Discounts Online Shopping Impulse Purchases

How do you currently track your spending?

What's your biggest money worry right now?

Have you ever had a budget that worked?

In 6 months, what would financial success look like for you?

6Priority Ranking

Rank these financial priorities from 1 (most important) to 5 (least important):

Build Emergency Fund

Save money for unexpected expenses

Pay Down Debt

Reduce or eliminate current debts

Improve Credit Score

Work on credit repair and building

Stop Overspending

Control spending and stick to budget

Learn Budgeting

Master financial planning skills

7Additional Information

How much could you realistically save/put toward debt each month?

What financial education do you feel you're missing most?

Is there anything else you'd like your financial coach to know?

Privacy & Confidentiality

All information provided will be kept strictly confidential and used solely for the purpose of providing financial literacy coaching services. Your data will never be shared with third parties without your explicit consent.

What happens next:
1. Your information is securely sent to your coach
2. You'll receive a confirmation message
3. Your coach will contact you within 24 hours