Client Intake – The Wealth Edit Group

Demographics

Step 1 of 6

Full Name * Please enter your full name.

Phone Number * Please enter a valid 10-digit phone number.

Email Address * Please enter a valid email address.

Physical Address * Please enter your physical address.

My address has changed in the last 2 years

Previous Address * Please enter your previous address.

Date of Birth * Please enter your date of birth.

Best Time to Contact * Please select your preferred contact time window.

Preferred Method of Contact *

Phone Call Email Text Message

Please select your preferred contact method.

Portal Credentials

Please provide your credentials for your credit monitoring portal. This information is kept strictly confidential and used only to review your credit reports on your behalf.

Monitoring Service Name * Please enter the name of your credit monitoring service.

Username * Please enter your monitoring portal username.

Password *

Please enter your monitoring portal password. Your credentials are fully encrypted and stored securely.

Identity Verification

Step 2 of 6

Social Security Number *

Please enter a valid SSN (XXX-XX-XXXX). Your information is encrypted and never shared.

Upload Social Security Card *

Drag & Drop or Click to upload Social Security Card

Supports PDF, PNG, JPG, JPEG (Max size: 5MB)

Please upload a copy of your Social Security Card.

Upload Driver's License, State ID, and/or Passport *

Drag & Drop or Click to upload ID documents

You may upload multiple files (PDF, PNG, JPG, JPEG, Max size: 5MB each)

Please upload at least one valid identity document.

Have you experienced identity theft? *

Yes No

Please select an option.

Have you filed an identity theft report before? *

Yes No

Please select an option.

Credit Goals

Step 3 of 6

What is your main goal? * (Select all that apply)

Buy a Home Buy a Car Increase Credit Score Remove Collections Business Funding Other

Please select at least one goal.

Please describe your goal * Please describe your other financial goal.

Target Credit Score * Please select your target score.

When do you need results by? * Please select your preferred timeframe.

Have you worked with a financial consulting specialist before? *

Yes No

Please select an option.

Please describe your experience * Please describe your previous experience.

Credit Profile Information

Step 4 of 6

Which bureaus have negative items? (Select all that apply)

Experian Equifax TransUnion

Approximate Credit Score * Please select your approximate score.

Number of Collection Accounts * Please enter a valid count (0 or higher).

Number of Late Payments * Please enter a valid count (0 or higher).

Any Charge-Offs? *

Yes No

Please select an option.

Any Repossessions? *

Yes No

Please select an option.

Any Bankruptcies? *

Yes No

Please select an option.

Bankruptcy Type * Please select bankruptcy type.

Miscellaneous

Step 5 of 6

How did you hear about us? * Please tell us how you found us.

Who referred you? * Please enter the referrer's name.

Would you like a free 15-minute consultation? *

Yes No

Please select an option.

A team member will reach out to schedule your consultation at your preferred contact time. We look forward to connecting.

Review & Submit

Step 6 of 6

Please review the details below. If you need to make any changes, you can use the progress bar above or click the Back button to navigate to the respective step.

1. Demographics & Credentials

Full Name

Phone Number

Email Address

Date of Birth

Contact Method / Time

Monitoring Portal Details

Physical Address

2. Identity Verification

SSN

Identity Theft Experenced?

Uploaded Social Security Card

Uploaded ID Documents

3. Advisory Goals

Main Goals

Target Credit Score

Desired Timeframe

Prior Consulting Specialist?

4. Profile Information

Negative Bureaus

Approximate Score

Collection Accounts

Late Payments

Charge-Offs / Repossessions

Bankruptcies

5. Miscellaneous

How you heard about us

Free 15-Minute Consultation

I confirm all information provided is accurate and I authorize The Wealth Edit Group to review my profile information on my behalf. * You must authorize The Wealth Edit Group to proceed.

The Wealth Edit Group

Demographics

Portal Credentials

Identity Verification

Credit Goals

Credit Profile Information

Miscellaneous

Review & Submit

1. Demographics & Credentials

2. Identity Verification

3. Advisory Goals

4. Profile Information

5. Miscellaneous

Application Received

Request Submitted

Demographics

Portal Credentials

Identity Verification

Credit Goals

Credit Profile Information

Miscellaneous

Review & Submit

1. Demographics & Credentials

2. Identity Verification

3. Advisory Goals

4. Profile Information

5. Miscellaneous

Application Received

Bespoke Consultation

Request Submitted