Referral to UCWB financial health services

Name of person making referral *

Email Address *

Organisation *

Department/program *

Phone - Office

Phone - Mobile

Has the referred person consented to this referral *

Yes - please complete the statement belowNo - the person is not eligible for assistance without consent for referral

Declaration of consent to refer

The below referenced referred person has provided *

Verbal consentSigned consent (below)

to the above referenced referrer to make this referral that includes personal information that relates to accessing UCWB’s financial counselling and financial capability services.

Referrer's signature *

Draw signature|Type signatureClear

Client (referred person) signature *

Draw signature|Type signatureClear

Personal details of referred person

First Name *

Last name *

Preferred name *

Date of birth *

MaleFemaleOther

Aboriginal/Torres Strait Islander? *

YesNo

Migrant/refugee? *

YesNo

Country of birth *

Interpreter required? *

YesNo

Language

Are you renting through a real estate agent? *

YesNo

If yes, name of agent

Are you renting through a community housing agency *

YesNo

If yes, name of agency

Do you have dependent children? *

YesNo

If yes, what are their ages?

Do you have a disability or other difficulty? *

YesNo

If other, please specify

Financial & personal circumstances of referred person

Experiencing difficulties paying rent or mortgage *

YesNo

At risk of being evicted *

YesNo

Behind in paying utility bills (gas, electricity, water, phone, internet) *

YesNo

Experiencing domestic and/or family violence *

Yes - but am still in the relationship and/or family homeYes - I have left the relationship and/or family homeNo

Experiencing financial abuse *

YesNo

Do you or does someone in your household gamble? *

Yes - meYes - someone in my householdNo

Experiencing dependence on alcohol and/or other drugs *

YesNo

Money going out has increased recently and/or over the past year *

YesNo

Money coming in has reduced recently and/or over the past year *

YesNo

Experiencing difficulties with day to day money management *

YesNo

Difficulty paying the following (tick all that apply)

If other, please specify

Client's main reason for referral *

UnitingCare Wesley Bowden Inc ABN 65 440 352 199

77 Gibson Street, Bowden SA 5007

Rev. 02/21 V2

Referral to UCWB financial health services

Referrer details

Declaration of consent to refer

Personal details of referred person

Financial & personal circumstances of referred person