Modern Financial Services Company
Client Intake — Confidential
Important:
I am not an attorney, CPA, or licensed financial advisor. I provide administrative advocacy and education only. All information is kept strictly confidential.
Contact Information
Full Name *
Email Address *
Phone Number
Life Insurance
Do you currently have any life insurance policies?
— Please select —
Yes
No
Policy Details
Insurance Carrier
Policy Number
Policy Type
— Select one —
Term Life
Whole Life
Indexed Universal Life (IUL)
Universal Life (UL)
Group (through employer)
Monthly Premium ($)
Coverage Amount ($)
Was an illustration shown at the time of sale?
— Select one —
Yes
No
Unsure
Did the illustration show "vanishing premiums"?
— Select one —
Yes
No
Unsure / Not applicable
Is this policy owned by your employer?
— Select one —
Yes
No
Current employment status (if employer-owned)
— Select one —
Actively employed (same employer)
Planning to leave or change jobs soon
Recently left this employer
Retired
Not applicable
Additional notes about this policy
Income & Expenses
If you got sick for a month, what percentage of your income would disappear?
Example: 75
Who else depends on your income (even if they don't live with you)?
When was the last time you had a 3-month emergency fund?
Do you count bonuses, commissions, or side income in your monthly budget?
— Select one —
Yes
No
If we looked at your bank statements, what category would shock you most?
What subscriptions do you still pay for but never use?
How much do you spend per month on things you forget 6 months later?
Do you actively track your spending — or just guess?
— Select one —
Yes, I track
No, I estimate
Debt & Assets
Which debt stresses you the most — and why?
Have you stopped opening statements for any account?
— Select one —
Yes
No
Do you ever pay one debt with another (even mentally)?
— Select one —
Yes
No
Have you ever skipped a debt payment for something urgent but not necessary?
— Select one —
Yes
No
If everything collapsed, what could you sell within 72 hours?
Do you know the withdrawal penalties for your retirement accounts?
— Select one —
Yes
No
How much of your wealth is tied up in things you can't quickly sell?
Are any of your "assets" actually liabilities in disguise?
Credit & Insurance
How often do you carry more than 50% of your credit limit?
— Select one —
Never
Sometimes
Often
Have you ever opened credit to feel safer — not because you needed it?
— Select one —
Yes
No
Are there accounts on your credit report you forgot about or don't recognize?
— Select one —
Yes
No
Do you know all the accounts where you're listed as an authorized user?
— Select one —
Yes
No
If your income stopped for 6 months, what would protect you?
Have you read your insurance policy in full?
— Select one —
Yes
No
Would your household survive financially if you died tomorrow?
— Select one —
Yes
No
Unsure
Who pays the bills if you're injured — not emotionally, but financially?
Emotional & History
What emotion makes you spend the most?
Who defined "success" for you — and have you ever questioned it?
How does your money behavior change when you feel powerless?
What money behavior would you be embarrassed for your kids to copy?
Are there any hidden accounts, assets, or debts no one knows about?
Have you ever lied on a financial aid, tax, or insurance form?
— Select one —
Yes
No
What part of your money life would you try to explain away if discovered?
Your Financial Vision
What does financial freedom look like to you — emotionally, practically, visually?
If you had zero debt and full control, what would your life feel like?
List your top 3 priorities for the next 12 months
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