Client Intake Form

Welcome! This form helps Semenya understand your full financial picture so your coaching sessions are personalized, focused, and effective from day one.

Personal Info

Financial Picture

Debt & Credit

Goals & Mindset

Coaching Prefs

Personal Information

Let's start with the basics so Semenya can get to know you.

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth

City & State

Employment Status

Household Size

How did you hear about Jordan Financial Group?

Your Financial Picture

This helps Semenya understand your income, expenses, and current financial situation. All information is completely confidential.

💰 Income

Monthly Take-Home Pay ($)

Secondary Income ($)

Other Income (SSI, benefits, etc.) ($)

🏠 Monthly Fixed Expenses

Rent / Mortgage ($)

Car Payment ($)

Insurance (auto, health, life) ($)

Utilities (electric, water, gas) ($)

Phone Bill ($)

Internet / Cable ($)

Childcare / School ($)

Subscriptions (Netflix, etc.) ($)

🛒 Monthly Variable Expenses

Groceries ($)

Dining Out / Takeout ($)

Gas / Transportation ($)

Personal Care / Clothing ($)

Entertainment / Fun ($)

Other Expenses ($)

💾 Savings

Current Savings Balance ($)

Monthly Amount Saved ($)

Retirement / 401k Balance ($)

Do you have an emergency fund?

Debt & Credit

Understanding your debt is the first step to eliminating it. Check all that apply and share what you know.

What types of debt do you currently have?

Estimated Total Debt ($)

Total Monthly Debt Payments ($)

Estimated Credit Score

Have you missed any payments in the last 12 months?

Any additional notes about your debt situation?

Assets (What You Own)

Home Value (if you own) ($)

Car Value ($)

Investment Accounts ($)

Other Assets ($)

🎉

You're all set, friend!

Your intake form has been submitted. Semenya will review everything and reach out within 24–48 hours to schedule your first coaching session. Your financial freedom journey starts now.

Open My Budget Template → Back to Main Site

Client Intake Form

Personal Information

Your Financial Picture

Debt & Credit

Goals & Financial Mindset

Coaching Preferences

You're all set, friend!