Please read the following statements carefully and sign below to indicate understanding of each provision.  Counselors must have this form signed before reviewing your financial information and before advising you regarding your specific situation.
Non-Discrimination Policy:
Our agency serves all members of the community.  We do not engage in the practices of discrimination in the selection and participation of clients in our programs or services with respect to race, religion, color gender, national origin or handicap.

I understand that I will be provided with a confidential money management interview.

I understand that in the event I am dissatisfied, I can utilize the Client Grievance Procedure.

Course of Action: 
I will be given a written assessment outlining a suggested plan of action that will be based on one of the following options:
a) I will handle any financial concerns on my own  or b) I may choose to enroll in the agency’s Debt Management Program in which the agency serves as a neutral third party negotiating with creditors to liquidate financial obligations.

Dual Role:
Our DMPs serve the dual role of helping you repay your debts and helping creditors to receive the money that you owe them.

Our agency receives funding in the form of donations and grants from individuals and entities that support financial counseling. A portion of the agency funding comes from voluntary contributions from creditors who participate in our Debt Management Program (DMP).  Since creditors have a financial interest in getting paid, most are willing to make a contribution to help fund our agency.  These contributions are usually calculated as a percentage of payment made through the DMP, up to fifteen percent (15%) of each payment received.  However, regardless of the creditor contribution, your creditor accounts will always be credited with one hundred percent (100%) of the amount you pay through us and we will work with all of your creditors, regardless of whether they contribute to our agency or not.

Impact on Credit: 
Your credit report is not impacted by you obtaining counseling through our agency.  Our agency will not disclose or provide any information about this counseling session to a credit reporting agency.

Your participation in a debt repayment program will not change anything which is already on your credit report.  If your credit report reflects that you have paid as agreed in the past, a debt management program can have a negative impact on a credit decision by a potential creditor, landlord or employer in the future.  In addition, creditors may report that you are on a debt management program and are not paying as originally agreed, although they have accepted the reduced payment plan.

It is important to note that if your credit report does not currently reflect a positive payment history, making consistent payments through the DMP may improve the credit worthiness review over time, as well as assist in paying down the overall indebtedness and improving credit scores.

Counseling qualifications: 
The consumer credit counselor conducting or supervising the session has been trained and certified in accordance with the NFCC standards.

Debt management services are not suitable for all debtors.  There are other ways, including bankruptcy, to deal with indebtedness.  You should also be aware that debts to creditors you repay through the plan may be able to be discharged through bankruptcy.  Counselors cannot provide legal advice about bankruptcy.

At some time in the future, your demographic information may be used for confidential research and/or a neutral third party may contact you to request an evaluation of the agency’s services.

I hold the agency, its employees, agents and volunteers harmless from any claim, suit, action or demand of my creditors, myself or any other person resulting from advice or counseling. 
Please indicate you have read and understand each provision.