How does CCCS help you?

 
You can fill out the form below online - to our secure server.
 

After you submit it, we will contact you to arrange an appointment.

You will then receive a letter confirming your appointment, along with other information about the counseling session.

How does CCCS help you?
How do I make an appointment?
Is there a fee for this service?
Our Service and Privacy Policy
How? Where? When?
Who supports the service?
What do we expect from our clients?
What services are provided?
Fill out our form now


THIS FORM IS FOR CREDIT COUNSELING ONLY - FOR BANKRUPTCY INFORMATION, CALL OUR OFFICE.
Please select your preference
  In-Person Counseling
  Counseling By Phone

Last Name
First Name
Client 1
Client 2
Address
City
State
Zip
Home Phone
Work Phone
# in Household
Status

 
Take Home Pay
Weekly
Monthly
Bi-Weekly
Semi-Monthly
Client 1
 
Client 2

Other Income
Source of Other Income
Weekly
Monthly
Yearly


Expenses
Weekly
Monthly

HOUSING
  Rent or Mortgage
 
  Oil
 
  Gas
 
  Electricity
 
 

FOOD
  Groceries
 
  Lunches
(Work & School)
 
 

TRANSPORTATION
  Car Payments
 
  Gasoline/Oil
 
  Insurance
 
 

INSURANCE
  Life (Whole/Term)
 
 

MEDICAL
  Insurance (Hospital/Medical)
 
  Doctor/Therapist/
Optometrist
 
  Dentist
 
  Perscriptions/
Medications
 
 

CLOTHING
  Family Clothes
 
 

EDUCATION
  Tuition
 
 

PERSONAL
  Alimony & Child Support
 
  Baby Sitter /
Day Care
 
  Entertainment
 
  Gifts (Birthdays, Holidays)
 
  Children's Allowance
 
  Pet Care
 
  Other

I/WE OWE THE FOLLOWING
CREDITOR, LAWYER, COLLECTION AGENCY NAME, ADDRESS, ZIP, TELEPHONE #
BALANCE OWED
DATE & AMOUNT OF LAST PAYMENT
SECURITY /CO-MAKER

Please press "Submit Information" button only once

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