Intake Form English

PRIVACY POLICY

This Counseling Agency respects the privacy of the people that come to us for assistance. We understand that the matters you discuss with us are very personal. All spoken and written information shared with us will be managed with our legal and ethical obligations to you, taken into consideration. We will not sell your personal information and we only share it
to provide you with counseling services.

Your “nonpublic personal information” (including total debt information, income, living expenses, and personal information concerning your financial circumstances) will be shared with creditors, funders, and others only after you sign the Counseling Services Authorization. We may also collect, use, and share anonymous aggregated case file information to evaluate our services, to gather valuable research information, and to design future programs.

Types of Information That We Gather About You:

• Spoken or written information on applications and other documents, such as your name, address, social security
  number, assets, and income;
• Information about your transactions with us, your creditors, or others, such as your account balance, payment
  history, parties to transactions and credit card usage; and
• Information we receive from a credit reporting agency, such as your credit history.

You May Opt-Out If You Do Not Want Us to Share Your Information:

• You may "opt-out" to prevent the disclosure of your nonpublic personal information to third parties (such as
  your creditors).
• If you opt-out we cannot share your nonpublic information and we cannot answer questions from your
  creditors. We need to share your information to provide you with most services.
• You may opt-out at any time by calling the Counseling Agency at the phone number listed on the Counseling
  Services Authorization provided with this Privacy Policy.

You May Opt-Out If You Do Not Want Us to Share Your Information:

• You may "opt-out" to prevent the disclosure of your nonpublic personal information to third parties (such as
  your creditors).
• If you opt-out we cannot share your nonpublic information and we cannot answer questions from your
  creditors. We need to share your information to provide you with most services.
• You may opt-out at any time by calling the Counseling Agency at the phone number listed on the Counseling
  Services Authorization provided with this Privacy Policy.

How We Use Your Information:

• If you do not opt-out we may share information that we collect about you with your creditors or others if we
  think it would be helpful to you, would help us counsel you, or when required by funders that make our services
  possible.
• We may share information about you to anyone as permitted or as required by law (e.g., if a Court requires us
  to provide it with documents).
• Within our organization, we restrict access to your information to those employees who need to know that
  information to provide services to you. We maintain physical, electronic, and procedural safeguards to protect
  your information as required by federal and state law.

Client Authorization

By signing below I authorize my employers, lenders, creditors, servicers, and others to share personal and
financial information with my Counselor and the Counseling Agency. I authorize my Counselor and the Counseling Agency
to collect information about my accounts and to share this information with others, including funders, as needed to
provide counseling services, to seek assistance from programs, or for related products and services. I authorize funders to contact me to evaluate programs that I participate in.

CLIENT ENGAGEMENT AGREEMENT

(This agreement is optional and does not impact the rest of the 3-in-1 form)

Today’s consumer is searching for real-time information on how to maneuver through the maze of financial products and

services, establish or rebuild credit, reduce debt and save for the future. Helping clients reach their potential through a

variety of services has never been more essential.

Financial counseling is an emerging field that supports clients as they work towards goals and strive to maximize their

financial potential. Through an ongoing, systematic and collaborative process, coaches that specialize in financial

capabilities can facilitate changes in clients’ financial habits so that they can reach financial security. Participating in a

regimented course of financial counseling services can increase the client’s sense of well-being and safety through

knowledge and promote changing behaviors that will improve their financial circumstance.

If you are interested in improving your financial capabilities, please agree to the following:

I am willing to commit to at least four sessions (minimum of one hour per session) over the course of 12 months and a

minimum of one follow-up survey within three months of the final session.

The first session must be a face-to-face session with a counselor. Upon submission of required documentation,

subsequent sessions can be conducted using alternative methods of communication such as: telephone, internet, Skype,

Smart Phone, etc.

I understand that my counselor will review and discuss an updated Action Plan for each session, and I will receive a copy.

COUNSELING AGENCY DISCLOSURES

Please Initial

For Client: