Counseling Request/Intake Form:
NAME:
ADDRESS:
CITY & STATE:             ZIP: 
E-MAIL:
HOME #:
CELL #:
MALE FEMALE       DATE OF BIRTH: 
   

On a scale from 1 to 10 (1 being the lowest it's ever been and 10 the highest it's ever been) - How would you rank your current level of financial stress?

LEVEL OF EDUCATION ATTAINED (or current year in school):
 (High School, Freshman, A.A., B.S., PhD, Vet, etc.): 


STUDENT      NON-STUDENT  [If non-student, see fee schedule]
 

SCHOOL CURRENTLY ATTENDING (if applicable):
CURRENT GPA:

MARITAL STATUS:
Single
Married
Divorced
Separated
Widowed
Engaged


 RACE:
American Indian/Alaskan Native
Asian
Black or African American
Hispanic
Native Hawaiian or Other Pacific Islander
White

PLEASE CHECK ALL AREAS THAT APPLY TO YOUR SITUATION:
Behind in monthly payments
No saving or spending plan
Too much credit (too many credit cards/loans)
Overspending
Expenses exceed income
Creditors have contacted you (by phone or mail)
Bankruptcy (Contemplated or filed)
Overdraft in last year (Insufficient funds)
Unexpected crisis
Marital or family problems
Gambling

 None of the above areas apply

ARE YOU CURRENTLY EMPLOYED?
 Yes
No

YOUR EMPLOYER:  


WHAT IS TOTAL MONTHLY HOUSEHOLD INCOME BEFORE TAXES?  


IF CURRENTLY A STUDENT, WHAT IS YOUR CURRENT MAJOR?  
WHAT IS YOUR ACADEMIC COLLEGE (i.e., Business, Engineering, etc.)?  
WHAT IS YOUR ANTICIPATED STARTING SALARY AFTER GRADUATION? 

DO YOU HAVE STUDENT LOANS?
 Yes
No (if no, skip to next section)

TOTAL FEDERAL STUDENT LOAN BALANCE (i.e., Stafford, Perkins):      

HAVE YOU CONSOLIDATED YOUR FEDERAL DIRECT LOANS (EITHER IN-SCHOOL OR OUT)?
Yes, I consolidated while in school
Yes, I consolidated after graduation
 No, not yet
No, I'm not eligible - no Direct Loans


 DO YOU HAVE ALTERNATIVE/PRIVATE STUDENT LOANS?
 Yes
No (if no, skip to next section)

TOTAL ALTERNATIVE STUDENT LOAN BALANCE:      

HOW MANY CREDIT CARD [AND STORE CARD] ACCOUNTS DO YOU CURRENTLY HAVE OPEN? 
HOW MANY CREDIT CARDS (WITH BALANCES) DO YOU CARRY? 

TOTAL CREDIT CARD BALANCE: 

TOTAL CAR LOAN BALANCE(S): 


TOTAL 'OTHER' LOAN BALANCE:    Specify other type 
OTHER LOANS = (doctor bills, home equity, consolidation, & other loans)

TOTAL DEBT:
TOTAL DEBT = (student loans, credit cards, car,& all other loans except home mortgage)


(WHAT IS YOUR ANTICIPATED TOTAL DEBT AT GRADUATION)? 

CHECK ALL OBLIGATIONS WHICH ARE CURRENTLY OVERDUE:
 Utilities
Telephone
Child/Spouse support
Credit card or other loans
Rent/Mortgage payment
Car payment
 Other (specify) 

NONE OF THE ABOVE ARE OVERDUE

DO YOU HAVE ANY INVESTMENTS:
YES    NO

IF YES, HOW MUCH? 

WHAT IS YOUR COUNSELING PREFERENCE?
 Face-to-face counseling
 Phone counseling
 E-mail counseling


 HOW DID YOU LEARN ABOUT OUR SERVICE?
 Website
 E-mail
 Brochure
 Workshop
 Financial Aid Office
 Friend
 Community Agency
 MU organization (student organizations, Extension, etc.)
 Other -- Please specify:



Anything else we should know about your situation ahead of time?



 


 What days/times work best to meet with a financial counselor or planner?