Date

Name Person 1:*

First

Last

Current Age Person 1:*

E-mail Person 1:*

Phone Person 1:*

Area Code

Phone Number

Profession Person 1:*

Employer Person 1:*

Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Name Person 2:

First

Last

Current Age Person 2:

Phone Person 2:

Area Code

Phone Number

E-mail Person 2:

Employer Person 2:

Profession Person 2:

1/5

**Please use whole numerical values only, not symbols, commas or decimals.

Salary/Wage Income (Before Taxes):*

Social Security/Pension Income (Before Taxes):*

Annual Savings/Retirement Plan Contributions:*

ASSETS

**Please use whole numerical values only, not symbols, commas or decimals.

Annuities:

Savings, Money Market, CDs

College Savings (529/Coverdell Plans)

Taxable Investments (Stocks, Bonds, Options, REITS, Mutual Funds

Employer Pensions Plans (Defined Benefit, MPPP, Profit Sharing)

Investment Real Estate (Office Buildings, Rental Properties)

IRAs, Roth IRAs, SEPs

401K, 403b, 457, TSP, Simple

Personal Property:

Closely Held Business Interests(Partnerships, Corporations, Limited Partnerships)

Home

Second, Vacation Homes

Total Assets**:

**If TOTAL ASSETS is blank, please check the fields in the assets section to make sure you only used numerical values, no symbols, commas, or decimals.

LIABILITIES

**Please use whole numerical values only, not symbols, commas or decimals.

Home Mortgage (First, Seconds, HELOCs)

Consumer Loans (Credit Cards, Student Loans, Car Loans, Etc.)

Investment Real Estate or Business Loans

Total Liabilities:

**If TOTAL LIABILITIES is blank, please check the fields in the liabilities section to make sure you only used numerical values, no symbols, commas, or decimals.

NET WORTH

Total Net Worth (Assets less Liabilities)

3/5

Please prioritize the financial assistance you are seeking (1-Top Priority, 2-Second....6-lowest):

Asset & Income Protection

Investment Strategy Planning

Retirement Planning

Financial Coaching/Counseling

Cash Flow Management (i.e. Spending Plan, Budgeting)

Estate Planning

Total: 0/21

Tell us about your most important financial concerns and what you would like to accomplish through this engagement.

Tell us about your most important non-financial concerns right now?

Describe how you envision your lifestyle 5 years from now. (What are you doing or becoming, where, how, etc)

Describe previous experiences working with financial advisors or financial therapists. What was good/unsatisfactory?

Tell us how you make important financial decisions?

4/5

Tell us about future financial changes that you wish to plan for. (i.e. family obligations /inheritances...)

During our review 3 years from now, what will need to have happened for you to be satisfied with your progress?

Tell us about past litigation involvements. What happened?

Describe your ideal relationship with a financial planner or financial therapist.

Is there anything else we need to talk about?

Where did you hear about us?

5/5

Initial Interview Form

To make the best use of our time together please complete and return this form to us before our meeting.

INCOME

**Please use whole numerical values only, not symbols, commas or decimals.

ASSETS

**Please use whole numerical values only, not symbols, commas or decimals.

**If TOTAL ASSETS is blank, please check the fields in the assets section to make sure you only used numerical values, no symbols, commas, or decimals.

LIABILITIES

**Please use whole numerical values only, not symbols, commas or decimals.

**If TOTAL LIABILITIES is blank, please check the fields in the liabilities section to make sure you only used numerical values, no symbols, commas, or decimals.

NET WORTH

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