Statement of Counseling Services and Release of Information

Please read the following statements carefully so that you will understand the procedures for the counseling session. Initial the line next to each statement to indicate understanding of that provision. For simplification, the singular is used even when the plural may apply.

I understand that Consumer Credit Counseling Services of Northeastern Iowa will provide a confidential, comprehensive, personal money management review.

I understand that the interview will be conducted by a certified consumer credit counselor or qualified professional counselor. All action plans, not completed by a certified consumer credit counselor, will be reviewed by a certified consumer credit counselor.

I understand that, in the event I am not satisfied with the service, I can utilize the Grievance Procedure.

I hereby authorize the staff of Consumer Credit Counseling Service of Northeastern Iowa to verbally, or in writing release, obtain or exchange timely and relevant information regarding my financial situation, with all attorneys, officers of the court, government agencies, accountants, creditors, collection agencies, credit bureaus, landlords, utility companies, social service agencies, and any other parties that have an interest in my indebtedness for the purpose of settlement or reduction of my current debt load.

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.  Nothing herein shall apply to actions or claims under the provisions of the United States Bankruptcy Code, 11 U.S.C. Sec. 101 et seq.

I will be given a written assessment outlining a suggested client action plan, which will be based on the following options:

• I will handle any financial concerns on my own with counseling assistance (Financial Counseling Only).
• I may choose to enroll in the agency's Debt Management Plan. Our DMPs serve the dual role of helping you repay your debts and helping creditors to receive the money owed them. In the event that the counselor suggests a Debt Management Plan, I will receive completed details of the requirements, responsibilities and procedures.
• I may choose to enroll in the Bill Paying Account or Representative Payeeship Account. Should I want information on them, the counselor will provide me with all details of requirements and rules.
• A counselor may answer questions about bankruptcy, but not give legal advice. If I want legal advice, I will be referred for appropriate assistance. While an attorney can make a recommendation to file bankruptcy, it is a personal choice based on individual circumstances. I will inform the agency of the decision if I file bankruptcy.
• I may be referred to another agency or agencies as appropriate for assistance with particular problems that have been identified.

At sometime in the future, my information may be used for confidential research and/or a neutral third party may contact me to request an evaluation of the agency's services.

My signature indicates that I have received a copy of this Statement of Services and Release of Information.