1. a) What life/financial goals would you like to accomplish in the next few months to a year? *

You can select more than one

Build an emergency savings fund

Start or expand my own business

Buy a home

Purchase a car

Purchase land and build a home

Save for retirement

Start investing

Other

4. What is your employment status? *

Check all that apply

Employed full time

Employed part time

Self-employed

Homemaker

Retired

Student

5. b) If you answered yes to the previous question, which statement(s) best describe what the outcome was

I reported it, someone followed up with me and the situation was resolved in a just manner

I reported it, someone followed up with me and the situation was NOT resolved in a just manner

I reported it and no one followed up with me about my report

I did NOT report it because I was able to resolve the manner to my satisfaction

I did NOT report it because I didn’t know how/who to report it to

I did NOT report it because I didn’t trust that anyone would do anything about it

I did NOT report it because I feared I would be subjected to retaliation

7. Do you have a good sense of how much money you make and how much you spend each month? *

Yes

No

9. I could handle a major unexpected expense *

This statement describes me:

Completely

Very well

Somewhat

Very little

Not at all

10. I am securing my financial future *

This statement describes me:

Completely

Very well

Somewhat

Very little

Not at all

11. Because of my money situation, I feel like I will never have the things I want in life *

This statement describes me:

Completely

Very well

Somewhat

Very little

Not at all

12. I can enjoy life because of the way I’m managing my money *

This statement describes me:

Completely

Very well

Somewhat

Very little

Not at all

13. I am just getting by financially *

This statement describes me:

Completely

Very well

Somewhat

Very little

Not at all

14. I am concerned that the money I have or will save won’t last *

This statement describes me:

Completely

Very well

Somewhat

Very little

Not at all

15. Giving a gift for a wedding, birthday or other occasion would put a strain on my finances for the month *

This statement applies to me:

Always

Often

Sometimes

Rarely

Never

16. I have money left over at the end of the month *

This statement applies to me:

Always

Often

Sometimes

Rarely

Never

17. I am behind with my finances *

This statement applies to me:

Always

Often

Sometimes

Rarely

Never

18. My finances control my life *

This statement applies to me:

Always

Often

Sometimes

Rarely

Never

19. Are you interested in 1:1 Financial coaching? *

Each participant will receive two 60 min coaching sessions

Yes

No