Financial Well-Being Assessment1

What was your immediate reaction to the intro recording we sent you? What thoughts and feelings came to you? *

Why are you interested in Financial Coaching? What are your expectations of what you'll gain from this process (financial and non-financial)? Use this space to describe your CURRENT financial coaching needs. *

1) When you were a child, what did you want to be when you grew up? *

2) Did you learn about money from your parents while you were growing up? *

Yes No

If yes, briefly describe what you learned. *

3) Did you learn about money from schooling/education while you were growing up? *

Yes No

If yes, briefly describe what you learned. *

4) Did you learn about money anywhere else while growing up? *

Yes No

If yes, briefly describe what you learned (and from where). *

5) Which of the following describes how you learned to manage your personal finances? (select ALL that apply) *

My parents proactively taught me I observed my parents' struggle and vowed to learn from their mistakes I observed my parents' success and wanted to achieve the same success they did I proactively learned through reading, studying, etc. I re-actively learned through trial and error as I moved through life

6) Which best describes your recollection of how your parents handled finances when you were growing up? *

They never talked about it They rarely discussed money They consistently argued/fought about money They frequently talked about money peacefully

7) What problems have you encountered in past relationships, as it pertains specifically to money? *

8) Looking back on your life, what would you say are the biggest financial mistakes you have made and what did you learn from them? *

9) When was the last time you spent money and instantly regretted it? What did you purchase? Why did you regret it? *

10) Have you been married before? *

Yes No

If yes, how was your relationship as it relates to finances? *

If yes, did you keep your money separate, or join all money together as one? *

11) When was the last time you INVOLUNTARILY missed work without pay? (i.e. - laid off, fired, health issues, etc.) *

Never < 1 year ago 1 - 2 years ago > 2 years ago

13) Which of the following financial setbacks have you faced in the last 20 years? (select ALL that apply) *

14) When was the last time you paid interest as a result of not paying off a credit card in full? *

Within the past Month Within the past Year More than 1 Year ago Never

15) Which of the following have you experienced due to your current financial situation? (select ALL that apply) *

Loss of sleep Stress & anxiety Depression Marriage conflict (out of the ordinary)

1) Are you currently in a relationship? *

Yes No

2) Do you have any children? *

Yes No

If yes, list names and ages below. *

If yes, do your children live with you? *

Yes No

If yes, have you had any discussions with your kids about money? *

Yes No

If yes, briefly describe your interactions. *

If no, do you plan on having children in the future? *

If you plan on having children in the future, how many? *

1 2 3 or more

3) Do you have aging parents who rely on you for financial support? *

Yes No

4) Are you comfortable discussing your finances with others? *

Yes No

If yes, who? (i.e. - family, friends, strangers, etc.) *

5) Do you have any professional advisors (tax preparer, attorney, financial advisor, money manager, insurance agent, etc.)? *

Yes No

If yes, list advisor types and your rating of this pro (names not necessary)? *

6) Do you lose sleep at night thinking about your finances? *

Yes No

7) How often do you actually sit down to review your finances, from a planning perspective? *

8) How much time would you say you spend on an average month viewing and paying bills? *

Does the above process cause you anxiety or stress? *

Yes No

9) Do you log transactions into an account register so you know your current balance? *

Yes No

10) Do you reconcile ALL credit card and bank account transactions, by comparing your data with what your institutions show? *

Yes No

11) Briefly describe 2 things in life you are truly passionate about (i.e. - Chad Peshke's passion is Changing Lives by helping people Make Finances Simple) *

12) If you already had all of the money you ever wanted, what would you do differently? In other words, what would you be doing in life if money was not a factor? *

13) If you were given $100,000 tomorrow, what would you do with the money? *

14) If you were given $500 tomorrow, what would you do with it? *

15) Which best describes your first financial thought when a mechanic says you need new brakes? *

There is no way I can afford this right now I'm glad I planned ahead for things like this

16) Does your employer provide matching for retirement savings (401k, etc.)? *

Yes No

If yes, provide details below. *

17) Does your employer provide a pension for your retirement *

Yes No

If yes, provide details below. *

18) How do you generally handle finances when "it rains & pours"? (i.e. - car breaks down just after your home air conditioning unit blows out while your daughter needs money for senior prom) *

I have to use a credit card that I can't pay off in full when the bill comes due I have money in the bank to completely pay for these situations

19) What total do you have in Savings solely for EMERGENCIES? (i.e. - money you could quickly access without penalty) *

< $5,000 $5,001 - $10,000 $10,001 - $25,000 > $25,000

20) What percentage of your income do you give away to your church and/or other causes? *

0 1 - 5% 6 - 10% > 10%

Do you desire to or wish you could give more? *

Yes No

21) What percentage of your income is currently being invested for retirement? (i.e. - 401k, IRA, etc.) *

0 1 - 5% 6 - 10% > 10%

22) Are you currently saving for your child's college education? *

Yes No I don't have children

23) Do you own your primary home? *

Yes No, but I own rental real estate No, I don't own any real estate

24) Other than home loans, what types of debt do you currently have? (select ALL that apply) *

25) What is the total amount owed on the debts mentioned above? *

26) Do you have any looming pressing financial need that needs to be taken care of in the next year? (i.e. - new car, adjustable home loan, etc.) *

Yes No

27) Is there anything happening in your life, right now, that could have a major impact on your financial future? *

Yes No

28) Have you ever borrowed from (or lent money to) a family member or friend? *

Yes No

If yes, how did it affect your relationship? *

29) Have you ever participated in “get-rich” schemes to quickly make up ground on improving your financial situation? If yes, briefly describe below. *

Yes No

30) How many credit cards do you have? (include joint cards) *

0 1 - 2 3 - 5 > 5

31) Why do you feel the need to have a credit card? (select ALL that apply) *

So I can buy things with money I don't have In case of an emergency...for protection To earn cash back/points rewards on everyday purchases For business expense tracking To be eligible for retailer/merchant discounts I don't have a credit card

32) Which best describes your mentality when on vacation as it relates to money? *

I don't think about money when I'm on vacation...life is too short I shouldn't be on this vacation...I can't really afford it I really don't have the money for this vacation...but I work hard and deserve it Glad I budgeted for this vacation so I know I have the money to pay for it

33) Which best describes your guilt level when making a purchase you aren't sure you can truly afford? *

Life is too short and I work hard...so I don't worry about it I feel initial guilt...then I purchase the item anyway I try to be frugal & keep spending to a minimum I don't buy things that aren't in my budget

34) Do you feel pressured to adhere to societal standards as far as what you own? (i.e. - best house, nicest car, clothes, jewelry, etc.) *

Yes No

35) Rate your level of happiness with your current financial position *

100% happy Content...but would still like to improve Not very happy Depressed

36) Are you happy at your current job? *

Yes No

37) Are you fulfilled with the work you are doing at your current job? Why or why not? *

38) What is your dream job/career? *

39) How would you feel if you lost your job tomorrow? What would be the ramifications for you, financial and non-financial? *

40) How is your physical health? *

Great Good Fair Poor

41) How are your finances currently affecting your health? *

A Lot Sometimes Rarely Not at all

42) What’s currently missing in your life? Where do you feel a voice (financial and/or non-financial)? *

1) What worries you about your future? *

2) What major purchases do you anticipate in the next five years? If any, provide more information below. *

3) Does anybody in your family (who depends on you financially) have a medical condition or other situation that would impact you financially? *

Yes No

If yes, please explain below. *

4) Do you plan on paying education expenses for any children or dependents? *

Yes No

If yes, provide more info below. *

5) At what age do you wish to retire? *

65 60 55 Younger

6) Briefly describe your definition of retirement. *

7) Write down 2 specific FINANCIAL goals you hope to achieve in the next 2 years *

8) Write down 3 specific FINANCIAL goals you hope to achieve in the next 10-15 years *

9) Which 3 choices below do you mostly want to improve with your finances? (select ONLY 3) *

10) Write down 2 LIFE goals (non-financial) of yours that money can help you achieve *

Financial Well-Being Assessment

YOUR PAST

YOUR PRESENT

YOUR FUTURE

Financial Well-Being Assessment

​YOUR PAST

YOUR PRESENT

YOUR FUTURE

YOUR PAST