Budgeting Referral Form

Referral Date

First Name

Last Name

Preferred Name

Date of Birth

Phone Number

Email Address *

Street Address

Post Code

Suburb

City

Country

Present concerns around budget

Ages of the people in the house

D.O.B of the youngest child

Do you have any goals?

Please tick the days that would best suit you

Monday

Tuesday

Wednesday

Thursday

Friday

You can select as many days as you like

Referrer's First Name

Referrer's Last Name

Referrer's Organisation

Referrer's Contact Number

I give my consent for the information provided in this referral form to be passed on to the appropriate staff *

I agree to accept budgeting advice and if I can't attend an appointment I will notify my Financial Mentor

I understand that this service is free and confidential and the budget service/or the budget advisers are not liable to me under any circumstances for their actions or any advice they give, however that liability arises (including through negligence).

I will do my best to keep to the agreed budget and arrangements and not to obtain further credit without first discussing it with my Financial Mentor.

In accordance with the Privacy Act 1993, Principles 3(b) and 11(d), I understand that this information is to be recorded. I understand that in rare cases the Ministry of Social Development may request my file to be transferred to either themselves or anot

I have been informed of the complaints procedure.

Budgeting - Referral Form

Budgeting – Presbyterian Support upper South Island