Financial Assessment, Counseling, and Follow-up

Financial Assessment
OMB Control Number: 3170-00xx
Expiration Date:

Contents
Demographics
Client Info
Disability Questions
Socioeconomic
Income & Benefits
Employment
Education
Income & Debt
Credit Report and Score
Tax Filing
Consumer Protection/Consumer Rights
Housing
Financial Capability
Banking & Savings Questions
Decision-making, Attitudes and Behavior Questions
Questions Specific to Clients to opt for Coaching

Demographics
Client Info
1.
2.
3.
4.
5.
6.
7.

First Name
Middle Initial
Last Name
Street Address and Zip
Email
Primary Phone
DOB
8. Gender (expression of identity)

9. Ethnicity:
1. Hispanic or Latino

2. Not Hispanic or Latino
10. Race
1. American Indian or Alaska Native
2. Asian
3. Black or African American
4. Native Hawaiian or Other Pacific Islander
5. White
6. Other
11. Nativity
1. US Born, Foreign born (Naturalized) US citizen, Foreign born non-citizen
12. Marital Status
1. Single, Married, Widowed, Separated, Divorced, Domestic Partner, Common Law
13. Language Preference
1. List for selection
14. Highest level of Education completed
1. List for selection (some HS through more than college)
15. Do you or a family member living in your household have a disability?
1. Yes = myself
2. Other = another family member has a disability
3. Both = myself and at least one other family member
4. No = No disability present
16. If yes, or other, what type of Disability do you or does someone else in your household have?
1. Permanent Mobility and Physical Impairments, including spinal Cord Disability; Head
injuries- Disabilities such as Acquired Brain injury or Traumatic Brain Injury,
2. Vision
3. Hearing
4. cognitive or learning disabilities
5. psychological disorders
6. intellectual or developmental disability
7. Other
17. Are you or a family member affiliated with the US Armed Forces? (Self, member of the immediate
family)
1. Retiree
2. Veteran
3. Reserves
4. Active-duty
1. Air Force
2. Army
3. Navy
4. Marine Corps
5. Coast Guard
18. Are you a student taking courses for credit?
1. Part-time
2. Full-time
3. Four-year college or university
4. Two-year community colleges
5. Vocational, technical, or trade school
6. Other
19. How did you hear about this program?

Disability Questions

1. Is there a specific accommodation that you need to participate in the counseling/coaching
services offered? One-on-one or group class?
1. Yes
1. American Sign Language Interpreter
2. Assistive Technology Devices
3. Large Print
4. Braille
5. Microphone
6. Screen Reader
7. Others?
2. No
1. Are you an active Vocational Rehabilitation Client?
2. Are you registered for services with the Workforce Investment System?

Socioeconomic
Income & Benefits
1. Do you receive WIC?
1. Eligibility unknown
2. Not eligible
3. Eligible, but have not applied
4. Application in process
5. Receiving benefit
2. Do you receive SNAP (food stamps)?
1. Eligibility unknown
2. Not eligible
3. Eligible, but have not applied
4. Application in process
5. Receiving benefit
3. Do you receive TANF?
1. Eligibility unknown
2. Not eligible
3. Eligible, but have not applied
4. Application in process
5. Receiving benefit
4. Current income sources and amounts
1. Total monthly non-cash benefits amount
1. Family Medicaid and Individual Medicaid
2. Food Stamps
3. Section 8 vouchers
4. Energy Assistance
5. Rental Assistance
6. State Child Health Insurance Program
7. Special Needs Trust
8. Pooled Trust
9. State waivers
10. Social Security Pension
11. Other
2. Total monthly cash benefits/income amount
1. Child support
2. Earned income
3. General assistance
4. Social Security Disability Income (SSDI)

5. Supplemental Security Income (SSI)
6. Temporary Assistance for Needy Families (TANF)
7. Unemployment insurance
8. Other
5. Household composition
1. Number of Adults 18 or over in Household
2. Number of Children under 18 in Household
3. Number of Children in Household at least 50% financially dependent on you

Employment
1. Employment situation
1. No job, not actively searching
2. No job; cannot work - temporary (e.g. new baby, full-time education),
3. No job; cannot work – permanent (e.g. permanent disability, retired)
4. No job and capable of working with my disability, but putting little effort into search
5. No job and capable of working with my disability but afraid to work because I could lose
my benefits
6. No job but actively searching
7. Employed, dissatisfied
8. Employed, satisfied
2. Are you currently receiving support in your employment search? Yes/No
1. If answered yes, then from which agency/organization?
Each of the below employment questions should be conditional upon these responses above:
•
•

“employed – dissatisfied”
“employed – satisfied”
3.
4.
5.
6.
7.

Employer type details
Hourly pay
Number of hours worked per week, on average
Paid leave (Y/N)
Current employee benefits
1. Health insurance
2. 401K
3. Life Insurance
4. Other
5. Employed since (date)

Each of the below employment questions should be conditional upon these responses above:
•
•
•

“No job and capable of working with my disability, but putting little effort into search”,
“No job and capable of working with my disability but afraid to work because I could lose by benefits”
“No job but actively searching”
3.
Unemployed since (date)
4.
Are you aware of Social Security Administration Work Incentive counseling services with return to
work focus?
1. Yes
2. No
3. Would like to know more

Education
1. What, if any, educational path is participant pursuing?
1. None
2. HS/GED
3. College
4. Vocational certificate

Each of the below education questions should be conditional upon the appropriate responses above:
2.

3.

4.

HS/GED progress
1. Not enrolled
2. Enrolled and in danger of dropping out
3. Enrolled and on track to completing
4. Obtained HS diploma/GED
College progress
1. Not enrolled
2. Enrolled and in danger of dropping out
3. Enrolled and on track to completing
4. Obtained 2-year college diploma
5. Obtained 4-year college diploma
Vocational certificate progress
1. Not enrolled
2. Enrolled and in danger of dropping out
3. Enrolled and on track to completing
4. Obtained vocational certificate

Income, Assets and & Debt
1. Total monthly income
2. Do you own any or all of the following assets (list, choose all that apply; measure neither increase
nor decrease)
1. Home
2. Car
3. Other
3. What is your recurring monthly debt amount?
4. Please list the following types of debt you currently have:
1. Student loan debt?
2. Credit card/consumer loan
3. Assistive Technology or Durable Medical Equipment Loan
4. Mortgage
5. What describes your current state of thinking regarding paying off your debt?
1. Not thinking about paying-off debts
2. Thinking about paying-off debts
3. Actively making a plan to pay-off debts
4. Pays-off consumer debt monthly, makes regular payments on larger debt like mortgage
and student loans

Credit Report and Score
1. How would you describe your use of credit?
1. Don’t have any credit cards or loans outstanding.
2. Have one or more credit card accounts, but pay them off in full every month.
3. Make the minimum payment on my credit cards.
4. Maxed out on my credit card accounts so use them sparingly to make purchases.
2. Consumer report (credit report) status
1. Unknown never pulled
2. Unknown, not recently pulled
3. Incorrect information on credit report – no action taken
4. Incorrect information on credit report– actions taken to correct it
5. Correct
3. If answered “Unknown”, why has the participant never pulled his/her credit report?
1. Wasn’t interested
2. Couldn’t
3. Don’t know how

4. Didn’t understand previously pulled report”
5. Didn’t know benefits of obtaining a report in the past
4. If answered “incorrect” or “correct”, how often does the participant review his/her credit record?
1. Infrequently – once or twice total
2. Frequently – every few years
3. Regularly – every 12 months or more
5. What do you believe is your current credit score?
1. Very high (750-850)
2. High (700-749)
3. Middle (660-699)
4. Somewhat Low (620-659)
5. Very Low (340-619)
6. Don’t Know/Don’t have a Credit Score
6. How sure are you of this score?
1. Very Sure
2. Sure
3. Unsure
4. Very Unsure
5. Don’t Know/Don’t have a Credit Score
7. Most recent credit report, score and date—
Note: Would you like to review a copy of your credit report and score now? If yes, you have an
option to share your social security number so we may get your credit report and score for you, or
you may access your own credit report at www.annualcreditreport.com. Providing your Social
Security number is voluntary however if you do not provide the SSN we will not be able to retrieve
your credit report and score.

Tax Filing
1. Did you file your income taxes? (Yes, No)
1. 2011
2. 2012
3. 2013
4. 2014
5. 2015
6. 2016
7. 2017
8. 2018
9. 2019
2. Do you have access to free tax assistance?
1. Yes
2. No
3. I don’t know
3. Have you ever claimed the Earned Income Tax credit?
1. Yes
2. No
3. I don’t know
4. If you filed a tax return in the past or this year did you use:
1. Free In Person Service
2. Filed Taxes Online for Free
3. Friend or Family prepared them for me
4. Paid to file Taxes online
5. Paid preparer
6. Self-prepared via paper forms

Consumer Protection/Consumer Rights
1. Have you ever experienced financial fraud or abuse? (Have you experienced financial
exploitation, the illegal or improper use of your money?)
1. Yes
2. No
2. If yes, do you know where to go to report the abuse?
1. Yes
2. No
3. Are you currently experiencing a problem with a consumer financial product or service?
1. Yes
2. No
4. Are you currently being contacted by a debt collector?
5. Would you like to learn how to submit a complaint to the Consumer Financial Protection Bureau?
1. Yes
2. No
6. Do you know the steps you should take to protect your identify?
1. Yes
2. No

Housing
1. Housing Situation Descriptions (which is the best description of your housing situation?)
1. Homeless – the individual/family has no place to live, is squatting or living out of doors
2. Living in temporary/transitional housing – the individual/family has no permanent place to
live, is living in a shelter or transitional residential program
3. Living in permanent but sub-standard housing – the individual/family is living in owned or
a rented space, may not be able to afford what it costs to maintain this situation, and
conditions are overcrowded, unsafe, or otherwise unsatisfactory and may not be fully
accessible for tenant with mobility issue etc.
4. Living in permanent, appropriate housing – the individual/family is living it its own or a
rented space, can afford to maintain this situation, and conditions are safe and
satisfactory
5. Living in Group Housing – the individual is living on its own in rented space with XXX
other people with disabilities.
1. How many other persons with disabilities are living in the same house?

Financial Capability
Banking & Savings Questions
1. Which of the following best describes your household’s finances?
1. The adults have shared finances
2. The adults have some shared finances and some separate finances
3. The adults have separate finances even though we share living space
4. I am the only adult in the household
5. DK/Refused
2. How much do you participate in making financial decisions for your household?
1. A lot
2. Some
3. Not at all
4. DK/Refused
3. Do you or does anyone in your household currently have a checking or savings account?
1. Yes
2. No
3. DK/Refused
4. What type or types of accounts do you or family members currently have?
1. Only checking account
2. Only savings account
3. Both checking and savings accounts
4. Other
5. DK/Refused
5. In the past 12 months have you or anyone in your household used any of the following methods
to access an account?
1. Bank teller
2. ATM/Kiosk
3. Telephone banking through phone call or automated voice/touch tone

6.

7.
8.
9.

4. Online banking through desktop, laptop, or tablet computer (e.g, IPad)
5. Mobile Banking through text messaging, mobile apps, or Internet browser or email on
phone
6. Other
7. Did not access an account in the past 12 months
8. Don’t Know/Refused
Are you or member of your household enrolled in Individual Development Account or other savings
program?
1. Yes
2. No
Amount of monthly living expenses
Amount of total emergency savings
Have you used these alternative loan/alternative financial services at least once? (past month, six
months, year, more than a year, never)
1. Check Cashing
2. Money order
3. Remittance
4. Payday Loan
5. Rent-to-own
6. Pawn Shop
7. Refund-Anticipation-Loan

Financial Decision-making, Attitudes and Behavior questions
1. Over the last 3 months, have you followed a personal budget, spending plan, or financial plan?
1. Yes
2. No
3. Don’t know
2. Do you currently have a least one financial goal?
1. Yes, I have a one or more goal(s) to (check all that apply)
1. Create a plan to use a budget
2. Reduce existing expenses
3. Increase savings
4. Increase income
5. Improve credit score
6. Establish/build credit
7. Pay bills
8. Reduce Debt
9. Access Assistive Technology Loan Fund
10. Access financial products/services
11. Access mortgage lending services
12. Access small business lending resources
2. No, I do not have a financial goal.
3. How confident are you in your ability to achieve a financial goal you set for yourself today?
1. Not confident

2. Confident
4. In the last 3 months, did you use an automatic deposit or transfer to put money away for a future
use such as saving for retirement or education?
1. Yes
2. No
3. Don’t Know
5. In the last 3 months, did you manually deposit a cash, check or other to put money away for a
future use such as saving for retirement or education?
1. Yes
2. No
3. Don’t Know
6. Have you set aside emergency or rainy day funds that would cover your expenses for 3 months,
in case of sickness, job loss, economic downturn or other emergencies?
1. Yes
2. No
3. Don’t Know
7. Over the past 3 months, would you say your household’s spending was less than, more than or
about equal to your income? Please do not include large, one-time purchases such as a house or
car.
1. Less than
2. More than
3. Equal to
4. Don’t know
8. In the last 3 months, have you paid a late fee on a loan or bill?
1. Yes
2. No
3. Don’t Know
9. Considering your financial, savings, and expenses situation, when you think about big ticket
items such as furniture, a refrigerator, an automobile, a television and things like that, do
you think it would be:
1. An excellent time to buy
2. A good time to buy
3. Only a fair time
4. A poor time to buy
10. Would you say your own personal finance situation is better now, worse now or about the same
as it was a year ago?
1. Better than a year ago
2. Same as a year ago
3. Worse than a year ago
11. Here are some ways people manage the way they spend and save. Which of these steps have
you taken in the last year?
1. Cut down on credit card purchases
2. Paid down debt/reduced the amount of money you owe
3. Taken on another credit card
4. Taken out additional loans/borrowed money
5. Postponed the purchase of a major item like an automobile or furniture
6. Taken money out of savings to cover living expenses
7. Sold car or house or other big item
8. Changed living arrangements in order to save money
9. Worked longer hours or taken a second job to earn more money
10. Postponed retirement

11.
12.
13.
14.
15.

Put more purchases on your credit card so you didn’t have to pay for things immediately
Made minimum payments on credit cards rather than paying them off immediately
Cut down on non-essential spending like restaurants or vacations
Shopped more at discount stores and warehouse clubs
Use layaway to make big purchases

Financial Attitudes and Behaviors (FINRA)
1. Do you feel better, worse or the same about your financial status compared to six months ago?
2. How would you describe your savings now when compared to six months ago, better, worse or
the same?
3. How would you describe your debt now when compared to six months ago, better, worse or the
same?
4. In a typical month, how difficult is it for you to cover your expenses and pay all your bills?
1. Very difficult
2. Somewhat difficult
3. Not at all difficult
4. Don’t know
5. Prefer not to say
5. Have you set aside any money for after high school education or other training for you or your
children?
1. Yes
2. No
3. Don’t Know
4. Prefer not to say
6. Have you ever tried to figure out how much you need to save for retirement?
1. Yes
2. No
3. Don’t know
4. Prefer not to say
7. Has your household experienced a large drop in income which you did not expect?
1. Yes
2. No
3. Don’t know
4. Prefer not to say
8. How confident are you that you could come up with $2000 if an unexpected need arose within the
next month?
1. I am certain I would come up with the full $2000
2. I could probably come up with $2000
3. I could probably not come up with $2000
4. I am certain I could not come up with $2000
5. Don’t know
6. Prefer not to say
9. In the last 5 years have you asked for any advice from a financial professional about any of the
following?
1. Debt counseling
2. Savings or investment
3. Taking out a mortgage or a loan
4. Insurance of any type
5. Tax planning
10. Do you take care of your own financial business?
1. Yes
2. No
11. Does someone assist you with your finances?
1. Yes
2. No

Questions Specific to Clients to opt for Coaching

2. Do you have a financial goal (s) that requires long-term savings or investment?
1. Yes
2. No
3. Don’t Know
4. Refused
5. Not applicable
3. What will you use your long-term savings/investment for?
1. Motor Vehicle
2. Motor Vehicle Modification
3. Home
4. Home Improvement/Modification
5. Small Business Development
6. Investment Account
7. Retirement
8. Education
9. Mobility Related Purchase (wheelchair, assistive technology, etc.)
10. Other
4. What other uses might you use this long-term savings for?
1. To travel back and forth to work
2. To improve access to employment opportunities
3. To improve mobility and/or sensory or cognitive functioning (purchase of new wheelchair,
Braille reader, VRS phone, prostheses, AT, etc. rehabilitation services/procedures not
covered by insurance)
4. To improve accessibility to apartment or home
5. To build an employment opportunity for myself
6. To prepare for my retirement
7. To take a course to improve job skills
5. Have you created a plan to achieve your goal?
1. Yes
2. No
3. Don’t Know
4. Refused
5. Not applicable
6. What is your target date for achieving goal?
1. 0-3 Months
2. 3-6 Months
3. 6- 12 Months
4. 1 -2 Years

7.

8.

9.
10.

5. 3-5 Years
6. 5-10 Years
7. More than 10 Years
What areas can the coach assist you with to achieve this goal?
1. Create a plan to use a budget
2. Reduce existing expenses
3. Increase savings
4. Improve credit score
5. Establish/build credit
6. Reduce Debt
7. Access Assistive Technology Loan Fund
8. Access financial products/services
9. Access mortgage lending services
10. Access small business lending resources
What goal achieved?
1. Yes
2. No
3. In Progress
What goal was achieved?
What percentage is complete? (Enter a percentage (20%, 30%, etc.)

Self-Sufficiency Matrix (for use with clients who opt-in to coaching)
Domain

Housing

1

Food

Child Care

Adult
Education

Health Care
Coverage

3

4

Homeless or threatened
with eviction.

In transitional, temporary or
substandard housing; and/or
current rent/mortgage payment
is unaffordable (over 30% of
income).

In stable housing that
is safe but only
marginally adequate.

Household is in safe, adequate
subsidized housing.

No job.

Temporary,
part-time
or
seasonal; inadequate pay, no
benefits.

Employed full time;
inadequate pay; few or no
benefits.

Employed full time with adequate
pay and benefits.

No income.

Inadequate income and/or
spontaneous or inappropriate
spending.

Can meet basic needs
with subsidy; appropriate
spending.

Household is on food stamps.

Can meet basic food
needs, but requires
occasional assistance.

Can meet basic food needs
without assistance.

Childcare is unreliable or
unaffordable, inadequate
supervision is a problem for
childcare that is available.

Affordable subsidized
childcare is available,
but limited.

Reliable, affordable childcare is
available, no need for subsidies.

Employment

Income

2

No food or means to
prepare it. Relies to a
significant degree on other
sources of free or
low cost food
Needs childcare, but none is
available/accessible and/or
child is not eligible.

Literacy problems and/or no
high school diploma/GED
are serious barriers to
employment.

Enrolled in literacy and/or GED
program and/or has sufficient
command of English to where
language is not a barrier to
employment.

Has high school
diploma/GED.

No medical coverage with
immediate need.

No medical coverage and great
difficulty accessing medical
care when needed. Some
household members may be in
poor health.

Some members (e.g.
Children) have medical
coverage.

Can meet basic needs and
manage debt without
assistance.

Needs additional
education/training to improve
employment situation and/or to
resolve literacy problems to
where they are able to function
effectively in society.

All members can get medical
care when needed, but may
strain budget.

5

Household is safe,
adequate,
unsubsidized
housing.
Maintains
permanent
employment with
adequate income
an benefits.

Income is sufficient,
managed; has
discretionary
income is able to
save
Can choose to
purchase any food
household
desires.
Able to select
quality childcare of
choice.

Has completed
education/training
needed to become
employable.
No literacy
problems.

All members are
covered by
affordable,
adequate health
insurance.

Domain

1

2

Mobility

No access to transportation, public
or private; may have car that is
inoperable.

Transportation is available, but
unreliable, unpredictable,
unaffordable; may have care but
u
no insurance, license, etc.

3

4

Transportation is available and
reliable, but limited and/or
inconvenient; drivers are
licensed and minimally insured.

Transportation is generally
accessible to meet basic
travel needs.

Community
Involvement

Not applicable due to crisis
situation; in “survival” mode.

Socially isolated and/or no social
skills and/or lacks motivation to
become involved.

Lacks knowledge of ways to
become involved.

Safety

Home or residence is not safe;
immediate level of lethality is
extremely high; possible CPS
involvement.

Safety is
threatened/temporary
protection is available; level of
lethality is high.

Current level of safety is
minimally adequate; ongoing
safety planning is essential.

Some community
involvement (advisory
group, support group), but
has barriers such as
transportation, childcare
issues.
Environment is safe,
however, future of such is
uncertain; safety planning
is important.

5
Transportation is rea
available and
affordable car is
adequately insured

Actively involved in
community.

Environment is
appare n t l y safe
and stable.