Confidential Online Assessment Form

To help you get started on the road to debt recovery, please complete this online assessment form. All your information will be treated with the strictest confidence and we absolutely do not share any of your information with any other party.

     

General Information
*First Name:
*Last Name:
Mailing Address:
*Community / Town:
*Home Phone:
Cell Phone:
E-Mail:
*Preferred Form of Contact: Home Phone      Cell Phone      E-Mail
   
Marital Status: Married / Common Law      Single      Separated / Divorced
Number Living in Household:

Financial Information
Employment Status: Employed      Self-Employed      Not Currently Employed

Please list your net monthly income sources and amounts:

Please list your monthly living expenses and amounts (excluding debt repayment)
Do you have any of the following expenses:
Medical      Alimony / Support / Maintenance

Please list your main assets (home, car, etc.):
Asset Value

Please list your main debts:
Creditor Balance Owing Monthly Amount

Referral Information
How did you hear about us?
If referral, who referred you?

Any Questions or Comments?

Security

Please enter the two security words from the box below (required):
 
 
* Required field

 

What our clients are saying...

"A very professional group of people with mainly all my best interests at heart. Very knowledgeable and a pleasure to deal with."

 

"I started my experience with lots of worries, fears, and anxieties. With each visit the fears evaporated slowly. I might get my life back. Thank you."

 

"This company was very understanding and helpful and didn't make us feel worthless for being in such a position."

 

"Haley & Associates treated me professionally yet still made me feel comfortable allowing me to feel a trust between us."