Financial Background Assessment Form
Complete this Financial Background Assessment Form to help us understand your current financial situation and habits. Please answer all questions as accurately as possible.
What is your current employment status?
*
Employed full-time
Employed part-time
Self-employed
Unemployed
Student
Retired
Other
What is your approximate monthly household income?
*
Please Select
Under $2,000
$2,000 - $4,999
$5,000 - $7,999
$8,000 - $11,999
$12,000 or more
Prefer not to say
How would you describe your current housing situation?
*
Own home (with or without mortgage)
Renting
Living with family
Other
How many people are financially dependent on you (not including yourself)?
*
How confident do you feel about your ability to manage your finances?
*
1
2
3
4
5
Please indicate how much you agree with the following statements about your financial habits.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I regularly track my expenses.
1
2
3
4
5
I have a monthly budget.
6
7
8
9
10
I save a portion of my income each month.
11
12
13
14
15
How comfortable are you with your current level of debt?
*
Not at all comfortable
1
2
3
4
Very comfortable
5
1 is Not at all comfortable, 5 is Very comfortable
How would you rate your overall financial health?
*
1
2
3
4
5
What is your primary financial goal for the next 12 months?
*
Save more money
Pay off debt
Increase income
Invest for the future
Other
If you wish, please share any additional comments about your financial situation.
Submit Assessment
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