Financial Mentorship Initiative Application

Name:

Email:

Date of birth:

Phone:

Is it okay to leave a voicemail?

Yes

Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Do you live in Lewis County? (If no, please list county)

Primary language:

Please select housing situation:

Own home

Rent home

Homeless

Other…

Are you a Veteran?

Yes

Marital status:

Single

Married

Divorced

Widowed

Other…

Do you have children or other dependents in your care? (if yes, please list how many)

Are you currently employed?

Yes

If yes, please list employer.

Current monthly income:

Do you currently have a bank account?

Yes

If yes, what type of account do you have?

Checking

Savings

Other…

How did you hear about Women United’s Financial Mentorship Initiative?

What are your financial goals?

What time commitment are you willing to make to learn how to reach your financial goals? (30-minute sessions once/week)

4 weeks

What are the current barriers to your financial success?

How stressful is your financial situation in relation to the rest of your life? (0 = not at all to 10 = very stressful) Feel free to share details if needed.

Are there additional services you need but do not know how to access?

Yes

If yes, please explain.

CLICK HERE if you agree to the following policies: Women United and all our volunteers are dedicated to protecting your confidential information. You have the right to request a copy of this application. By signing below, you authorize Women United (WU) to share your application information with a financial mentor. Women United does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry) disability, marital status, sexual orientation or military status, in any of its activities or operations.

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