Personal Finance Snapshot

Name *

First Name Last Name

Your Age *

Email *

example@example.com

Phone Number *

Area Code Phone Number

Are you single or married?

Your Spouse's Name

First Name Last Name

Your Spouse's Age

Your Spouse's Phone Number

Area Code Phone Number

Your Spouse's Email

example@example.com

Do you have any children or other dependents? *

Yes No

How many dependents do you have?

What are your children's and/or dependents' ages? Please list from oldest to youngest

Do you currently work with a monthly budget or spending plan? *

Yes No

What are some of the main things you would like to learn about during our coaching sessions? *

What is your total gross annual household income? *

Your total household earnings before taxes and insurance are withheld.

What is your monthly take home pay? *

What you are paid out each month after taxes, insurance premiums, and retirement contributions.

Do you have any additional monthly income sources besides work? *

Yes No

Please select the sources from where you receive this income.

Side Gigs Social Security Pension/Retirement Withdrawals Disability/Unemployment Alimony/Child Support

What is the total amount you receive from non-employment sources each month combined?

Do you have an emergency fund? *

Yes No

Emergency fund dollar amount

Do you regularly contribute to any non-retirement savings or investment accounts? *

Yes No

How much per month do you contribute to this account?

Do you regularly contribute to an Educational Savings Account or a 529 plan? *

Yes No

If you are contributing to an ESA or 529, how much do you contribute each month?

Do you rent or own your residence? *

Own Rent

What is the remaining balance on your mortgage?

Are you current on your payment? *

Yes No

What is your current monthly payment? *

What is the total value of all vehicles in your household? *

Please list each vehicle and its approximate value *

How much cash do you have in all savings accounts? *

What is the total balance of your brokerage investments? *

Non-retirement investments.

Do you have money saved in retirement accounts like a 401(k), 403(b), or IRA? *

Yes No

How much are you contributing to retirement each month?

What is the total balance of all of your retirement accounts (IRA's, 401k's, pension lump-sum value, etc.)? *

Do you own a business? *

Yes No

Short description of your business.

What do you do?

What is this business's average annual gross revenue?

Do you own rental properties? *

Yes No

What is the approximate total value of these properties?

Do you have non-mortgage debt? If yes, please indicate the types and balances below. *

Yes No

What types of non-mortgage debt do you have? (Mark all that apply and detail applicable amounts below).

Total credit card debt.

Total student loan debt.

Total car debt.

Total personal loans.

Total 401k/pension loans.

Total medical debt.

Total tax debt.

Total home equity loan debt.

Total owed on electronic devices.

Total rental property debt.

Total family loans.

If you have any debts not accounted for above, list them here.

When is the last time you pulled a copy of your credit report? *

Within the past 6 months Within the past year Within the past 3 years More than 5 years/never have

Submission of your snapshot form is the first step in starting the coaching process. Once you have read the terms below, hit the Submit Now button and you will be redirected to schedule your first appointment. Select a day and time on my calendar for our first appointment.

The following terms apply to the duration of our coaching agreement:

If you are married, I require both husband and wife to attend our appointments. In a married household, both husband and wife must be on the same page for a financial plan to be effective. If your spouse cannot attend at our scheduled time, we will reschedule so that he or she can.

By agreeing to work with me, you understand that my fees are non-refundable and that if you do not show up to your scheduled appointment, you will forfeit your session for the month.

If you need to reschedule, let me know at least 24 hours in advance and I will work with you to find a new appointment time. If we are within the 24-hour timeframe and you cancel, I reserve the right to consider that month’s session forfeited, but will allow room for grace in extreme circumstances.

Lastly, I require you to be an active participant in this process. You will get out of this what you put into it. I devote myself to your well-being in this process, and I require that you devote yourself to that goal as well.

Coaching Agreement terms and conditions.

I accept.

Prove you're not a robot! Enter the message as it is shown. *

Biographical

Income Sources

Savings

Housing

Assets

Debts

Coaching Agreement and Final Submission