INITIAL SUMMARY CONTACT FORM (NEW CLIENTS)

* Please print all names DATE:

NAME of
CLIENT / MR

MRS

MS / CHRISTIAN DATE OF
SURNAME: NAMES: BI BIRTH:
ADDRESS: Partner’s Name:
PHONE
NUMBER: / S.T.D.
CODE / OCCUPATION: / AGES OF
CHILDREN:
Sex
1.Male
2.Female
3.Group / Relationship
1.Single
2.Single Parent
3.Family/Children
4.Couple
5.Divorced
6.Extended
Family Household / Age
1.Under 18
2.18 to 24
3.25 to 34
4.35 to 44
5.45 to 54
6.55 to 64
7.Over 65 / Accommodation
1.Fully Owned
2.Mortgage
3.Private Rent
4.Public Rent
5.Other
Boarding
Homeless / Personal Income
1.$0 - $20,000
2.$20,001 – $40,000
3.$40,001 – $60,000
4.$60,001 – $80,000
5.$80,001 +
6.Not Stated
7. Not Applicable / Household Income
1.$0 - $20,000
2.$20,001 – $40,000
3.$40,001 – $60,000
4.$60,001 – $80,000
5.$80,001 +
6.Not Stated
7. Not Applicable
Employment
1.Full-Time
2.Part-Time
3.Casual
4.Government Payments
5.Self Funded Retiree
6. Self-Employed
7. Other Income
8. No Income / Area
1.Yarrabah
2. Palm Island
3. Torres Strait
4. Cairns
5. Cardwell
6.Tully
7. Jumbun
8. Euramo
9. Bilyana
10.Kennedy
11. Cape York
12. Other / Referred By
1.Emergency Relief Provider
2.Housing Service
3.Money Management Worker
4.Community Organisation
5. Government Organisation
6. Legal Centre
7. Creditor
8. Financial Counsellor (other)
9. Centrelink
10. ITSA
11. Utility Company
12. Self
13. Other / Referred To
1.Emergency Relief Provider
2.Housing Service
3.Money Management Worker
4.Community Organisation
5. Government Organisation
6. Legal Centre
7. Creditor
8. Financial Counsellor
9. Centrelink
10. ITSA
11. Utility Company
12. Self
13. Other
Origin
1 Aboriginal
2.TorresStrait
Islander
3. Combined
Indigenous Origin
4. Non - Indigenous
Language
1.English
2.Creole
3. Not Stated
4. NESB
Presenting Case as a result of
  1. Alcohol and/or other drugs 11. Gambling
  2. Bankruptcy 12. Financial Literacy
  3. Budgeting 13. Housing
  4. Business Failure 14. Insufficient Income
  5. Change of circumstances 15. Mental Illness/Disability
  6. Child support issues 16. Relationship Issues
  7. Contract Dispute 17. Superannuation release
  8. Credit/debt issues 18. Taxation Issues
  9. Disaster (Natural) 19. Utilities
  10. Family Violence 20. MONEY MANAGMENT/
NILS
21. Other
DATA ENTRY
ID NUMBER
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Checked ByREPORTED BY:______
(Please print)

INITIAL UPDATE FORM

Date:
REPORTED BY:
FAXED TO HEAD OFFICE
(07) 4031 5883 / Client Name:
Data Base Number
MMP

Workshop 1

Nils

Workshop 2

Workshop 3

Workshop 4

2nd Nils

Tax Help

Referred to Financial Counselling
File Closed
Did the client obtain a financial management skill?
YES NO
If Yes what skill was identified?
Head Office use only
Date Processed:
Name:
Community Education
TOPIC: No:
/ FINANCIAL COUNSELLING

1st Case
2nd Case
3rd Case
Presenting Case
1.Addictions
2.Bankruptcy
3.Budgeting
4.Business Failure
5.Change of circumstances
6.Child support issues
7.Contract Dispute
8. Credit/Debt Issues
9. Disaster (Natural)
10.Financial Literacy
11.Housing
12.Insufficient Income
13.Mental Illness
14.Relationship Issues
15.Superannuation release
16.Taxation Issues
17.Utilities
18.Other
Case Resolved

Case Not Resolved

File Closed
Quote from Client about the service!
______
______
______