Self-Assessment/Survey for Coaching
Email address *
The two things that most worry me about my financial situation are ?
Your answer
If I could improve these two issues I would feel:
Your answer
Rank the spending areas below in terms of which makes up the biggest part of your monthly expenses with 1 being the biggest expense and 10 being the smallest expense. *
If you do not have any expenses in one of the areas, sclect NA.
1
2
3
4
5
6
7
8
9
10
NA
Car payment
Utilities, including cell phone
Rent or mortgage
Credit card debt
Student loans/tuition/educational expenses
Dining out and entertainment
Food (groceries)
Child care
Other
If I had more money I could
Your answer
I know the approximate amount of all that I owe
On a 1 to 5 scale, how satisfied are you with your level of debt, 1 being unsatisfied and 5 being completely satisfied
unsatisfied
completely satisfied
I know the approximate total of all my bank, savings and investment accounts
On a 1 to 5 scale, how satisfied are you with your savings 1 being unsatisfied and 5 being completely satisfied
unsatisfied
completely satisfied
In the past year, I have overdrawn a bank account
In the past year, I have paid a bill late
What gets in the way of reaching my financial goals?
Your answer
Rank the following areas of your financial life. Which areas need the most work or focus with 1 being the highest priority and 8 being the lowest priority.
1
2
3
4
5
6
7
8
Tax concerns or planning
Insurance
Retirement planning or other investing
Emergency savings account (rainy day fund)
Spending plan or budget
Credit score
Debt or credit card management
Student loans/Tuition/Educational expenses
I spend time on managing my money:
I would like to work with a coach because:
Your answer
My household net income (after taxes) is less than $53,000
Write your full name:
Your answer
Write your full address including street, city and zip code:
Your answer
What is your email address:
Your answer
What is the best phone number to reach you:
Your answer
What days and times are you available to meet with a coach:
Your answer
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