Name:
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First Name
Last Name
Email:
*
Phone:
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(###)
###
####
Number of Children
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0
1
2
3
4
5
6
7 or more
I know how to budget.
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I use a budget to help manage my money.
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I live paycheck-to-paycheck.
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I spend less than I earn.
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I have “fun money” planned into my budget.
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I pay my bills on time.
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I am prepared for annual bills (ex: insurance, auto registration, pest control).
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I save for major purchases and pay cash for them.
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I research major purchases in advance.
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Most of my purchases are made on impulse.
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I am aware of how much I spend each month on groceries, dining out and clothing.
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Spending money on items that I don’t need but desire strongly is a priority for me.
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Shopping provides an emotional outlet for me.
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I give money to charitable organizations.
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I receive a tax refund of over $500 each year.
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I believe that living on a budget can have a positive impact on my financial wellness.
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I believe that living on a budget is oppressive and will detract from my ability to enjoy life.
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I believe that it is wise to save toward an emergency fund.
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I have an emergency fund of $1,000 or more.
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I only use my emergency fund for emergencies.
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After using my emergency fund for emergencies, I replenish the account as soon as possible.
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I deposit money into savings each month.
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I regularly invest for retirement.
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I regularly invest for collge.
If you have no children, please skip this question.
I believe that I will be finacially prepared for retirement.
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I believe that I will be financially prepared for my children's college expenses.
If you have no children, please skip this question.
I use overdraft protection regularly.
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I reconcile my bank statement each month.
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I use check cashing services.
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I use credit cards to purchase items that I can’t afford.
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I use credit cards to receive cash back benefits and/or points.
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I have more than two credit cards.
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I use my credit card more frequently than my debit card.
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I pay my credit card balances in full each month.
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I make the minimum payment on credit cards and other debts.
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I have asked someone to co-sign a loan for me within the past few years.
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I have a home equity loan.
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I keep my student loans in forbearance whenever possible.
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I borrow money from family and/or friends.
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I make use of pay day loans.
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I check my credit report at least once annually.
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I believe that I need credit cards to live and to make ends meet.
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I believe that I will always be in debt.
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I am committed to providing my children with their wants whether I can afford to or not.
If you have no children, please skip this question.
I prioritize saving for retirement above saving for my children’s college education.
If you have no children, please skip this question.
I teach my children about how to manage money.
If you have no children, please skip this question.
I loan money to family members.
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I co-sign loans for others.
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I am accountable to a spouse or friend regarding my finances.
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I have specific financial goals.
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I use most of the money from tax returns, bonuses and raises to advance my financial goals.
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I know my approximate net worth.
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I believe that setting specific financial goals can have a positive impact on my financial wellness.
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I believe that knowing my net worth will encourage me on my financial wellness journey.
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