COUNSELING REQUEST

Student Financial Success offers one-on-one counseling to students. If you would like counseling services or more information about the services, please fill out the form below.

Counseling request form:

Name:
Address:
Address:
City:	State
Zip:
Telephone Number:
E-mail Address:
Gender:	Male Female
Age

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?

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

Are you currently employed?	Yes No
Your Employeer
What is your total montly houshold income before taxes?
What is your current major?
What is your academic college (i.e. Business, Engineering, etc.)?
What is your anticipated starting salary after graduation?

Do you have student loans? Yes No

Total Federal student loan balance (i.e. Stafford, Perkins)

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/private loans?	Yes No
Total Alternative Student Loan Balance

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 type
OTHER LOANS = doctor bills, home equity, consolidation, other loans
Total Debt
TOTAL DEBT = student loans, credit cards, carall other loans except home mortgage
What is your 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

Do you have any investments?	Yes No
If yes, how much?

What is your counseling preference?
Face-to-face counseling
Phone counseling
E-mail counseling

How did you learn about our service?
Website
Email
Brochure
Workshop
Financial Aid Office
Friend
Community Agency
Student organization
Other-- Please specify

Anything else we should know about your situation ahead of time?

What days/times work best to meet with a financial counselor or planner?