LCDC Counseling Intake

Personal Information

First Name

Middle Name

Last Name

Email

Phone Number

Address

Street Address

City

State

Zip Code

Household and Demographic Information

Date of Birth

Month

Day

Year

Birthday Month Calc

Birthday Day Calc

Birthday Year Calc

Date of Birth

Gender

Race/Ethnicity

Other Race Detail

Household Size (Number of people living in your home, including yourself)

Number in the household who are under 18 years of age

Annual Household Income (earned by all individuals living in of your home, including yourself)

$

Highest level of education completed

Less than High School	Two-year degree (AA)
High School Diploma or GED	Four year degree (BS, BA)
Trade, Vocational or Professional Certification	Post-Graduate Degree (Master's or Above)
N/A

Current housing status

OwnRent

How long have you lived at your current address?

Years

Months

Monthly rent

$

per month

Purchase price of house or unit

$

Monthly mortgage payment

$

per month

Service Type

Financial Background

Place of Employment

Your Occupation

Employment Status

Do you receive public aid benefits

Yes

No

Not Sure

Do you have a budget

Yes

No

Do you have a savings and/or checking account?

Yes - Checking Account
Yes - Savings AccountYes - Both Checking and Savings AccountsNo

Do you currently have any debt?

Yes

No

How much?

Do you currently have savings?

Yes

No

How much?

What is your Credit Score?

Combined net worth of household members, any assets owned i.e. homes, cars, boats, etc.

$

Goals

Coaching needs or reasons for engaging (e.g. rental assistance, credit building for home ownership, general credit building, opening a new savings/checking account, building savings, budgeting, debt management, etc.)

Notes/Financial Goals

Timeline to Achieve Goal(s)