Credit Repair Client Intake Form

Credit Repair Client Intake Form

Complete this intake questionnaire to share your contact information, credit concerns, goals, and supporting documentation.
Program and Client Contact Information
Client intake date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full legal name

First NameMiddle NameLast Name
Preferred name (optional)
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Current mailing address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City / State / ZIP

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Best contact method
Preferred contact time
Credit Reports and Dispute History
Are there former names or addresses appearing on your credit report?
If yes, list only those relevant to a reporting error
Which recent credit reports do you have?
Credit scores (optional)
Date credit scores checked

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you disputed credit report errors before?
If yes, when and with which bureau or creditor?
Has a creditor, collector, or bureau already responded?
Credit Concerns and Goals
Credit concerns (select all that apply)
Other credit concern
Inaccurate account or item details
Primary reason for seeking help
Other primary reason
Your most important credit goal
Target date (if any)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is there a pending application?
Would you like education on payment history, utilization, and budgeting?
Have you experienced identity theft or filed a fraud report?
Are any listed accounts currently subject to a lawsuit or court order?
Do you have active collection correspondence or debt validation notices?
Are you currently working with another credit repair company?
Other information that may help us evaluate your concerns
Supporting Documents, Contact Consent, and Acknowledgment
Supporting documents available
I agree to be contacted about this inquiry by
May our office send appointment reminders and service updates through your selected methods?
Client acknowledgment
Client signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Office Use Only
Assigned Representative (Office Use Only)
Client File Reference (Office Use Only)
Intake Status (Office Use Only)
Report Review (Office Use Only)
Documentation Outstanding? (Office Use Only)
Next Action / Follow-Up Date (Office Use Only)
Should be Empty:

Credit Repair Client Intake Form

Program and Client Contact Information

Credit Reports and Dispute History

Credit Concerns and Goals

Supporting Documents, Contact Consent, and Acknowledgment

Office Use Only