Intake Form | Budget Brain Ai

First name

Last name

Phone

Email

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Age Range

Approximate Total Unsecured Debt Amount

Other Debts? Please specify, include dollar amounts

Main Creditors & Approximate Balances (Example: Chase Visa - $12,000) - Include APR/Interest if possible

Other debts - Include APR/Interest if possible

Debts written-off/with collections

Approximate Total Monthly Minimum Debt Payments

Approximate Monthly Household Income (SSI, Disability, Pension) AFTER TAXES/DEDUCTIONS

Any Recent or Ongoing Hardships?

Reduced income after retirement

Medical or health challenges

Increased living costs (food, utilities, etc.)

Other (describe briefly below)

Describe recent hardship

Additional Details or Concerns - Anything else to help the AI understand your situation (e.g., fixed income only, wanting to avoid bankruptcy, creditor calls stressing you out)

Rent / Mortgage

Utilities (gas, water, electric, phone, etc.)

Transportation (Car, Uber, Bus) Gas and Insurance

Medical / Health Insurance/ Prescriptions

Groceries and Household Items

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