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OFFICE FOR STUDENT MONEY MANAGEMENT

Client Information Form

Ready for a remote appointment with one of our peer financial coaches? If so, please fill out this form so we can better serve you and your financial-planning needs.

All information provided is confidential.

First Name: 
Last Name: 
Email address: 

Gender:
Female
Male
Prefer Not To Answer 

Date of Birth

Marital Status:
Single
Married - How long? 
Divorced - How long? 

Highest Educational Level Attained:
Less than High School
High School Diploma
Associate's Degree
1 year of undergraduate
2 years of undergraduate
3 years of undergraduate
4 years of undergraduate
5+ years of undergraduate
Undergraduate degree
Some graduate
Graduate degree

Are you a current student?
Yes
No
If so, what is your major? 

Are you the first person in your family to attend college?
Yes
No

Ethnicity
White
Hispanic
Native American
African American
Hawaiian/Pacific Islander
Other (please specify)

Job status
Full-time
Part-time
Seasonal
None

Occupation 

Payment Frequency
Weekly
Bi-weekly
Monthly
Semi-monthly

Contact information
Local Street Address: 
Phone Number: 
Cell Phone: 

Do you have any financially dependent children?
Yes
No
If “yes,” how many? 

Do you have any other financial dependents?
Yes
No
If “yes,” how many? 

Household Monthly Take-Home (Net) Pay:
Gross Pay

Where do you currently reside?
Residence Hall
Apartment
House
With family
Other

What is your current rent/house payment? 

Please indicate the reason(s) for your visit (Check all that apply):
Money Management/Budget
Credit Report Questions
Behind in Monthly Payments
Financial Aid Questions
Student Loan Counseling
Considering Bankruptcy
Repayment of Loans
Set up Savings Plan
Gambling
Want to Establish Credit
Too Much Debt
Rent/Mortgage Questions
Unexpected Crisis
Medical Expenses
Unemployment
Legal Issues
Settle Old Debts
Conflicts with Others
Other (Please Specify) 

Please indicate how you heard about the Office for Student Money Management

Friend
Relative
Classmate
Brochure/Flyer/Poster
Career Center
Guest Speaker
WSU Counseling and Testing Center
Housing/Dining
Student Legal Services
Other WSU Office
Financial Aid
Student Affairs
Registrar
Newspaper Article
Student Health Center
Resident Assistant
Website
Academic Advisor
EAP
OSMM Employee
Bank or Credit Union
Other (please specify)