Date
First Name
Last Name
Employee ID
Department
Job Title
Company Email
Phone Number
All information provided in this intake form will be kept strictly confidential and used solely for the purpose of providing personalized debt management education and support within the scope of our corporate wellness program.
Do you have any concerns regarding your current financial situation?
If yes, please briefly describe:
Do you have any outstanding loans (e.g., student loans, personal loans, auto loans, mortgage)?
If yes, please specify:
Loan Type | Approximate Amount ($) | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Are you currently able to consistently save money?
Have you ever experienced difficulty managing your debt in the past?
What is your primary financial goal?
Please Indicate Your Level of Interest (High, Medium, Low):
Topic | Level of Interest (1=high, 2=medium, 3=low) | ||
|---|---|---|---|
A | B | ||
1 | Foundational Debt Management: | ||
2 | Understanding Debt: | ||
3 | Types of debt (credit cards, loans, etc.) | ||
4 | Impact of debt on financial health | ||
5 | Distinguishing between good and bad debt | ||
6 | Budgeting and Expense Tracking: | ||
7 | Creating a realistic budget | ||
8 | Tracking expenses effectively | ||
9 | Identifying areas for cost reduction | ||
10 | Credit Scores and Reports: | ||
11 | Understanding credit scoring models | ||
12 | Obtaining and reviewing credit reports | ||
13 | Strategies for improving credit scores | ||
14 | Financial Goal Setting: | ||
15 | Determining Financial priorities | ||
16 | Creating short, mid, and long term financial goals | ||
17 | Implementing action steps | ||
18 | Advanced Debt Management Strategies: | ||
19 | Debt Consolidation: | ||
20 | Pros and cons of debt consolidation loans | ||
21 | Balance transfer strategies | ||
22 | Evaluating consolidation options | ||
23 | Debt Negotiation and Settlement: | ||
24 | Communicating with creditors | ||
25 | Negotiating lower interest rates or payment plans | ||
26 | Understanding debt settlement risks | ||
27 | Card Management: | ||
28 | Optimizing card usage | ||
29 | Avoiding late fees and penalties | ||
30 | Understanding interest rates and APRs | ||
31 | Student Loan Management: | ||
32 | Understanding different repayment plans | ||
33 | Exploring loan forgiveness options | ||
34 | Strategies for paying down student debt | ||
35 | Mortgage Management: | ||
36 | Understanding different mortgage products | ||
37 | Refinance options | ||
38 | Strategies for paying off a mortgage faster | ||
39 | Emergency Fund Planning: | ||
40 | Determining adequate emergency fund amounts | ||
41 | Strategies for rapid emergency fund savings | ||
42 | Where to store emergency funds safely | ||
43 | Retirement Planning & Debt: | ||
44 | How debt affects retirement | ||
45 | Strategies to eliminate debt before or during retirement | ||
46 | Balancing debt repayment with retirement savings | ||
47 | Financial Mindset & Behavioral Finance: | ||
48 | Understanding emotional spending habits | ||
49 | Developing a positive financial mindset | ||
50 | Overcoming financial anxiety |
Webinars
In-Person Workshops
One-on-One Consultations
Online Resources (e.g., articles, videos, tools)
Group Q&A Sessions
Self-Paced Online Courses
Mornings
Lunch Breaks
Afternoons
Evenings
Weekdays
Weekends
Specific Days/Times
1st choice
2nd choice
Thank you for completing this form. We are committed to supporting your financial well-being.
Client Intake Form Insights
Please remove this Client Intake Form Insights section before publishing.
Let's break down the client intake form, analyzing its purpose, structure, and the strategic insights it aims to gather:
1. Purpose and Intent:
2. Structure and Content:
Client Information:
Confidentiality Statement:
Current Financial Situation (Optional):
Debt Management Education Topics - Interest Levels:
Preferred Learning Format:
Preferred Time/Days:
Additional Comments/Questions:
Client Signature:
3. Strategic Insights:
4. Key Considerations:
By carefully analyzing and utilizing the insights gained from this client intake form, corporate wellness programs can effectively address employee debt management challenges and promote financial well-being.
To configure an element, select it on the form.