NJCA Financial Coaching Pre-Screen Form

NJCA Financial Coaching: Information

We appreciate your interest in our FREE financial coaching services.
New Jersey Citizen Action’s financial coaches will work one-on-one with you to make lasting improvements to your financial situation. We will meet as often as you need in order to help you:

* understand your financial story
* learn good money managing habits
* work to reach your goals

Your needs and interests drive the coaching experience. You choose the goals you want to achieve, including increased savings, decreased debt, improved credit, decreased expenses, increased income and/or reduced financial stress.

INTERESTED IN ENROLLING IN THIS SERVICE? Please complete the information below.

Question Title

* 1. Name and Contact Information

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Please tell us which of the following you would like to work on with a coach. Which areas are a high priority for you? Low priority?

	1 Low Priority	2	3 Neutral	4	5 High Priority
Better spending habits	Better spending habits 1 Low Priority	Better spending habits 2	Better spending habits 3 Neutral	Better spending habits 4	Better spending habits 5 High Priority
Pay my bills on time	Pay my bills on time 1 Low Priority	Pay my bills on time 2	Pay my bills on time 3 Neutral	Pay my bills on time 4	Pay my bills on time 5 High Priority
Improve my credit	Improve my credit 1 Low Priority	Improve my credit 2	Improve my credit 3 Neutral	Improve my credit 4	Improve my credit 5 High Priority
Deal with debt	Deal with debt 1 Low Priority	Deal with debt 2	Deal with debt 3 Neutral	Deal with debt 4	Deal with debt 5 High Priority
Increase savings	Increase savings 1 Low Priority	Increase savings 2	Increase savings 3 Neutral	Increase savings 4	Increase savings 5 High Priority
Create a monthly money plan (budget)	Create a monthly money plan (budget) 1 Low Priority	Create a monthly money plan (budget) 2	Create a monthly money plan (budget) 3 Neutral	Create a monthly money plan (budget) 4	Create a monthly money plan (budget) 5 High Priority
Purchase a home	Purchase a home 1 Low Priority	Purchase a home 2	Purchase a home 3 Neutral	Purchase a home 4	Purchase a home 5 High Priority
Purchase a vehicle	Purchase a vehicle 1 Low Priority	Purchase a vehicle 2	Purchase a vehicle 3 Neutral	Purchase a vehicle 4	Purchase a vehicle 5 High Priority

Other (please specify)

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* 3. Is there anything else you’d like to share with us regarding your interest in financial coaching?

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* 4. What are your current sources of income? (e.g., earnings from work, child support, Social Security)

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* 5. What is your approximate annual household income (gross) from all sources?

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* 6. Are you currently employed

Full time

Part time

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* 7. How many people are in your household?

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* 8. How did you hear about NJCA’s Financial Coaching Program?

NJCA (Other NJCA service, NJCA event)

NJCA website/facebook

Instagram

Nonprofit/Community Org

Flier

Friend, relative

Newspaper Ad

Walk-In/Tax preparation

Church

School

Employer

Bank/Financial Institution

Other (please specify)

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* 9. Please tell us which location (Newark or Jersey City) and what days/times are best for you to meet with a coach:

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* 10. I have read the above description of NJCA’s Financial Coaching Program and would like to enroll in this service. I am ready, willing, and able to establish new financial practices to meet my financial goals. Please contact me to enroll.

Signature (type name)

Date: