1x1 Financial Coaching Application

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Financial Coaching is free and confidential and is brought to you by Arlington and Alexandria's Virginia Cooperative Extension (VCE) Master Financial Education Volunteers. Coaching sessions are based on one's needs; coaches help with budgets, debt, answer financial questions, and provide helpful resources.

For more information, please visit https://arlington.ext.vt.edu/ If you have any questions, please contact Aisha Salazar, VCE Family & Consumer Sciences Agent, at asalazar@vt.edu

Email *

Date *

YYYY

Phone number

First Name *

Last Name *

Goals you want to focus on (debt, retirement, budget, etc.). Try to be specific. You can select more than one goal. *

Pay off Debt

Budgeting

Pay for school

Build Emergency Fund

Retirement Planning

Improve Credit Score

Recovery after Identity Theft/Financial Scams/etc.

Purchase a car

Purchase a house

Learn about money management

Financial hardship due to Covid-19

Other:

Required

Where do you live *

Arlington

Alexandria

Washington D.C.

Falls Church

Fairfax

Other:

Family Situation (Married, Single, Children, etc, Other dependents) *

Monthly income for client and any spouse *

Housing situation (Rent, Own/Mortgage) *

Debt/Credit (Types, Amounts Owed, Interest Rates, Monthly Payment Amounts (Late/On Time), Credit problems?). Answer to the best of your knowledge. *

Gender *

Female

Male

Other:

Head of Household? *

Yes

Income Level *

Moderate

Low

Very Low

Extremely Low

High

Race & Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Other:

Required

Please add any other information you would like to provide.

Financial Coaching Agreement. Please read and sign. I understand that all my financial information will be confidential. My coach is my financial educator and cannot give me legal or financial advice, but can present me with resources, strategies and encouragement during coaching sessions. I understand that my coach will not make decisions for me or make contact with creditors or others on my behalf. Making decisions and taking action will be my sole responsibility. I understand that as a participant to this pilot program I will not receive legal advice or professional financial services. My coach will be there to support and encourage me during the term of the program. Ultimately, I am responsible for my actions. Neither Virginia Cooperative Extension (VCE) or Financial Coach will be held liable for any financial decisions I make as a result of this program. Please sign your name below. *

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