Lead Type: _________ Appointment Date: ______________________ Time:__________
Need Spanish? Video: Phone: In-Home:
CLIENT QUALIFICATION INFORMATION (CQF)
Personal Info
Relationship: __________________
Name: ___________________________________ Name: ___________________________________
Phone: __________________________________ Phone: __________________________________
Email: ___________________________________ Email: ___________________________________
Birthdate: ___________ Age: _______________ Birthdate: ___________ Age: _______________
Tobacco: Y / N Height: _____ Weight: _____ Tobacco: Y / N Height: _____ Weight: _____
Health/Risk Info
_________________________________________ _________________________________________
_________________________________________ _________________________________________
_________________________________________ _________________________________________
_________________________________________ _________________________________________
_________________________________________ _________________________________________
Financial Info
Mortgage Amount: ____________ Term: _____ Mortgage Payment: _________ Value: _________
Other Debts: ______________________________ _____________________________________________
Other Assets: ______________________________ _____________________________________________
Employed: Disabled: Retired: Unemployed: Employed: Disabled: Retired: Unemployed:
Occupation: ________________________________ Occupation: ________________________________
Income: ____________________________________ Income: ____________________________________
Need
Primary Goal/Concern: ____________________________________________ On Both?: _____________
Beneficiary: _______________________________________________________________________________
Do you have children? Yes No Ages: ________________________________________________
Additional Notes
Prowered by
