Client Questionnaire

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Name: *

Date of Birth:

Enter a two-digit month, two-digit day, and four-digit year. N

E-mail Address: *

Home Phone:

Cell Phone

Zip or Postal Code:

Home Address:

City:

State:

Dependents / Date of Birth:

Enter a two-digit month, two-digit day, and four-digit year. N

How did you hear about us?:

Do you have a Financial Advisor? If yes, who?:

CLIENT DATA

1. What has been positive for you with your finances over the years?

2. Complete the following statements about your financial situation:

I worry that:

I’m frustrated that:

I wish that:

3. What do you want to change the most about your financial situation?

4. What is your total household income:

Option<$50k

$50k-$75k

$75k-$125k

$125k-$200k

$200k-$300k

$300k+

5. Are you sure you will have sufficient assets to retire at your desired age and lifestyle?:

Do you have consumer debt? Check all that apply.

Bank credit cards (Visa, MasterCard, etc.)

Department store cards

Student loans

Car loans

Other

Enter your approximate total consumer debt

7. How do you hope to benefit from working with Budget Wise Consulting?

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