NOTE: If you have impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about counseling, please talk to your counselor about arranging alternative accommodations.
 
About Us and Program Purpose: Catholic Charities Financial Health (CCFH) is a non-profit, HUD approved comprehensive housing counseling agency. We provide free education workshops and a full spectrum of housing counseling including pre-purchase, foreclosure prevention, non-delinquency post-purchase, rental, and homeless counseling. We serve all clients regardless of income, race, color, religion/creed, sex, national origin, age, family status, disability, or sexual orientation/gender identity. We administer our programs in conformity with local, state, and/or federal anti-discrimination laws, including the federal Fair Housing Act (42 USC 3600, et. seq.). CCFH also provides confidential, comprehensive personal money management interviews should you choose to pursue a one-on-one financial counseling arrangement. You understand that a certified consumer credit counselor will conduct the interview and all action plans not conducted by a certified consumer credit counselor will be reviewed by a certified credit counselor. As a program participant, please affirm your roles and responsibilities along with the following disclosures and initial, sign, and date the form on the following page.
 
Client and Counselor Roles and Responsibilities:
 

Counselor’s Roles & Responsibilities	Client’s Roles & Responsibilities
Reviewing your financial goals and your finances; this includes your income, debts, assets, and credit history.	Completing the steps assigned to you in your Client Action Plan and attending education workshop(s) as recommended.
Preparing a Client Action Plan that lists the steps that you and your counselor will take in order to achieve your financial goals.	Providing accurate information about your income, debts, expenses, credit and employment.
Preparing a household budget that will help you manage your debt, expenses, and savings.	Attending meetings, returning calls, providing requested paperwork in a timely manner.
Your counselor is not responsible for achieving your financial goals, but will provide guidance and education in support of your goals.	Notifying CCFH or your counselor when changing a financial goal.
Neither your counselor, CCFH employees, agents nor directors may provide legal advice.	Retaining an attorney if seeking legal advice and/or representation in matters such as foreclosure or bankruptcy protection.
_______/______ Initials Termination of Services: Failure to work cooperatively with your counselor and/or CCFH will result in the discontinuation of counseling services. This includes, but is not limited to, missing three consecutive appointments, engaging in unethical or illegal financial activities, or providing the counselor with intentionally incorrect information.

 
Should I Seek One-on-One Counseling: I understand that, in that process, I will be given a written assessment outlining a suggested client action plan which will be based on the following options: I may choose to handle financial concerns on my own, I may continue services with CCFH, and I may attempt to implement a debt strategy with or without the assistance of CCFH. I understand that CCFH has no responsibility or obligation for any past, present or future credit rating I receive.
 
Agency Conduct: No CCFH employee, officer, director, contractor, volunteer, or agent shall undertake any action that might result in, or create the appearance of, administering counseling operations for personal or private gain, provide any preferential treatment for any person or organization, or engage in conduct that will compromise our agency’s compliance with federal regulations and our commitment to serving the best interests of our clients.
 
 
 
 
 
Agency Relationships: CCFH has financial or professional affiliations with HUD, NeighborWorks America, the State of Wisconsin, the City of Green Bay, Federal Home Loan Bank, DMCC, Ecumenical Partnership for Housing, Integrated Community Solutions, and eHomeAmerica. As a program participant, you are not obligated to use the products and services of CCFH or our partners. CCFH also receives funding from various sources, which include, but are not limited to: United Way support, voluntary contributions from DMCC, general community support (corporate, professional, church, individuals…), and grants from private foundations.
 
Alternative Services, Programs, and Products & Client Freedom of Choice: CCFH has a first-time homebuyer program. However, you are not obligated to participate in this or other CCFH programs and services while you are receiving counseling from our agency. You may consider seeking alternative products and services from entities including the Federal Housing Administration (FHA) for first-time homebuyer loan programs, and FISC or NeighborWorks for other first-time homebuyer programs. You are entitled to choose whatever real estate professionals, lenders, and lending products that best meet your needs.
 
Referrals and Community Resources: You may be provided a community resource list which outlines the county and regional services available to meet a variety of needs, including utilities assistance, emergency shelter, transitional housing, food banks, and legal aid assistance. This list may also identify alternative agencies that provide services, programs, or products identical to those offered by CCFH and its exclusive partners and affiliates.
 
 

_______/______ Initials

Privacy Policy & Practices, Complaint Resolution Process/Client Bill of Rights/Non-discrimination Policy: I/we received a copy of CCFH’s Privacy Policy & Practices, Complaint Resolution Process, Client Bill of Rights and Non-discrimination Policy. 
 
Errors and Omissions and Disclaimer of Liability: I/we agree CCFH, its employees, agents, and directors are not liable for any claims and causes of action arising from errors or omissions by such parties, or related to my participation in CCFH counseling; and I hereby release and waive all claims of action against CCFH and its affiliates. I have read this document, understand that I have given up substantial rights by signing it, and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of liability to the greatest extent allowed by law. If any provision of this document is unenforceable, it shall be modified to the extent necessary to make the provision valid and binding, and the remainder of this document shall remain enforceable to the full extent allowed by law. This provision shall not apply to actions or claims under the United States Bankruptcy Code, 11 U.S.C. 101, et seq.
 
Quality Assurance: In order to assess client satisfaction and in compliance with grant funding requirements, CCFH, or one of its partners, may contact you during or after the completion of your services. You may be requested to complete a survey asking you to evaluate your client experience. Your survey data may confidentially be shared with CCFH grantors.