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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?
EDUCATION:
Level of education attained (or current year in school):
High school Freshman Associates Bachelors Masters Doctoral Vet med Other
Are you a:
Student Non-Student [If non-student, see fee schedule on Clinic site]
School that you are currently attending (if applicable):
Iowa State University DMACC Not applicable
Current GPA: (#.##)
DEMOGRAPHICS:
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 Multi-racial
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
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 (skip to next section) Your employer is: What is your total monthly household income before taxes?
Yes No (skip to next section)
Your employer is:
What is your total monthly household income before taxes?
IF CURRENTLY A STUDENT,
STUDENT LOANS:
Do you have student loans?
Yes No (if no, skip to next section)
Total federal student load balance = 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 any alternative student loans (i.e., Partnership Loans)?
Total alternative student loan balance (i.e., Partnership Loans):
DEBT:
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 loan types: Other loans = (doctor bills, home equity, consolidation, & other loans)
Total debt =
Total debt = (student loans, credit cards, car,& all other loans except home mortgage)
If currently a student, what is you 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
Utilities Telephone Child/Spouse support Credit card or other loans Rent/Mortgage payment Car payment Other (specify)
None of the above are overdue
INVESTMENTS:
Do you have any investments?
Yes No (if No, skip to next section)
If Yes, how much?
CHECK ONE OF THE FOLLOWING:
Homeowner (mortgage fully paid) Mortgagor (own property covered by mortgage) If Mortagor, what type of financing do you have? HUD Loan VA Loan Conventional Loan Potential Mortgagor (would like to buy) Renter (occupy rental property) Potential Renter (residence hall -- would like to rent) Homeless Other (specify):
Homeowner (mortgage fully paid) Mortgagor (own property covered by mortgage)
If Mortagor, what type of financing do you have? HUD Loan VA Loan Conventional Loan
Potential Mortgagor (would like to buy) Renter (occupy rental property) Potential Renter (residence hall -- would like to rent) Homeless Other (specify):
COUNSELING:
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 ISU organization (student organizations, Extension, etc.) Other -- Please specify:
Would you prefer to meet with a Counselor who is a student or a professional?
Professional Student
Anything else we should know about your situation ahead of time?
What days/times work best to meet with a financial counselor or planner?
