Senior Financial Security Assessment Form
Assess financial stability, fraud protection, and support needs for seniors using a clean, premium, easy-to-complete form.
Financial Profile and Household Context
Age range of respondent/senior
*
55–64
65–74
75–84
85+
Living situation
*
Alone
With spouse/partner
With family
With caregivers
Assisted living
Other
Household size
*
Primary source(s) of income
*
Pension
Salary
Savings
Family support
Investment income
Other
Financial management approach
*
Manages finances independently
Manages finances with help from family
Manages finances with help from caregiver or professional
Someone else manages finances
Income, Expenses, and Debt Stress
Monthly income range
*
Under $1,000
$1,000-$1,999
$2,000-$2,999
$3,000-$4,999
$5,000-$7,499
$7,500 or more
Prefer not to say
Monthly essential expenses range
*
Under $1,000
$1,000-$1,999
$2,000-$2,999
$3,000-$4,999
$5,000-$7,499
$7,500 or more
Prefer not to say
Debt burden level
*
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
Ability to cover an unexpected expense
*
Yes, easily
Yes, with some difficulty
Only if I borrow or use credit
No
Prefer not to say
Briefly describe any recurring financial pressure or expense concern
Financial Security and Fraud Protection
Which of the following do you use for managing money or account access?
*
Phone
Email
Online banking
Mobile payment apps
Other
How often do you review statements or account activity?
*
After every transaction
Weekly
Monthly
Less often than monthly
Never
How confident do you feel spotting scams or fraud attempts?
*
Not confident
1
2
3
4
5
6
7
8
9
Very confident
10
1 is Not confident, 10 is Very confident
Which protections do you currently use?
Do you need help with fraud prevention or financial planning follow-up?
*
Yes, fraud prevention help
Yes, financial planning follow-up
Yes, both
No, not at this time
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