Money Mentors Financial Counselling Form/Paperwork Pack

FINANCIAL COUNSELLING SERVICE

Welcome to Money Mentors Financial Counselling Services. We look forward to working with you.
This paperwork can also be completed and/or downloaded online at http://www.moneymentors.org.au/contact/ Links located in bottom left corner. Accessible via computer, tablet, or phone
Section 1

1.1 Personal Information - General
Name

First NameMiddle NameMiddle Name
Surname
Surname
Date of Birth

DayMonthYear
Date
Gender

MaleFemaleDiverse gender identity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number

Area CodePhone Number
Work Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Email
Partner:

YESNO
If attending with your partner, please complete a Client Partner Details Form (Also located on this website).
Partner/Spouse Name

First Name Middle NameSurname
Partner/spouse Surname
Surname
Partner Date of Birth

DayMonthYear
Date
Partner Phone Number

Area CodePhone Number
Partner Email
example@example.com
1.2 Have you and/or your partner/spouse visited Money Mentors (Previously-Finucare) previously?
1.3 Are you aware of any persons whom you have/had a personal (eg. a relationship break-up ) or legal issue with, attending our services?
1.4 Are you currently appointed as any of the following:

Community Treatment OrderGuardianPublic TrusteeCentrelink Money Management VoluntaryCentrelink Money Management Involuntary
1.5 Are there any adults over 18 living in the house?
If yes and you are applying for debts related to Household expenses such as electricity, gas, water or rent you must complete details of other Adults living in the house.

Other Adults (over 18) Living in the House - Complete this section if you answered yes to the above

	Name	DOB	Relationship to Applicant
1
2
3

Paperwork Checklist

◻ 3 months of current, bank account statements (from today back).

◻ Latest loan account statement for each of the following requiring help: credit cards, store
cards, mortgages, personal loans, hock shops or other debt you may have.

◻ Rent or Mortgage payment receipts if not on bank statement.

◻ 3 most current payslips (if working).

◻ Centrelink Detailed Income and Asset Statements (include all benefits and deductions)

□ Copies of Utilities Bills requiring help (Alinta, Synergy, Kleenheat, Origin or other)

If self-employed additional documents which would be helpful are;

◻ 3 months of current, bank transaction statements from all accounts. Personal and business
accounts (from today back)

◻ 3 BAS statements if monthly or 1 BAS statement if lodged quarterly

◻ Profit and loss statement (if available)or last tax return

Additional Paperwork Required for Other Debts

□ Proof of any other income (as listed at 2.6)

□ If you are applying for Grants or ER related to household expenses such as gas, electricity,
water or rent, please supply income and bank statements for ALL adults in the house.

If you are having trouble obtaining these items, contact our office to discuss ASAP.
OFFICES

MANDURAH: 61B Pinjarra Road, MANDURAH WA 6210. Co-located with PCLS.

Hours- Monday-Friday 9am-4pm

Ph: 9581 1281 Email: admin@moneymentors.org.au

BYFORD: Inside St Aidan's Community Centre, 21 Clifton Street, BYFORD WA 6122

Hours- Tuesday-Thursday 9am-3.30pm

Ph: 9581 1281 Email: admin@moneymentors.org.au

Outreach Locations

Please call Mandurah office 9581 1281 for appointments/enquiries

KWINANA Outreach: Frank Konecny Community Centre, 2 Skottowe Parkway, PARMELIA WA 6167

WAROONA Outreach: Waroona Community Resource Centre, 10 Henning Street, WAROONA WA 6215

Office times are subject to change according to staff availability. If we are not available, please feel free to leave us a message on 9581 1281 or email admin@moneymentors.org.au, and we will return your enquiry as soon as possible.

Section 3

Please fill in the below income and expenditure to the best of your ability. If a field does not apply, leave it blank. Please leave the TOTAL fields blank.

FORTNIGHTLY Income and Expenditure

	$
HOUSING TOTAL
Rent/Board
1st Mortage
2nd Mortgage
Council Rates
Home & Contents Insurance
House Repairs
Strata Levies/Fees
MEDICAL TOTAL
Medical Insurance
Doctor
Dentist
Chemist
Psy/Counselling
Clothing/Grooming and Cosmetics
Entertainment
Club/Sporting Fees/Gym
Holidays/Xmas
Gifts/Birthdays
Pocket Money - Children
Alcoholic Drinks
Cigarettes/Tobacco
Donations/ Other
Pool/Gardening
UTILITIES TOTAL
Electricity
Heating - Wood
Gas
Water Usage/Water Rates
Mobile Phone
Internet/Home Phone
Streaming/Foxtel/Subscriptions

Section 3 Continued

FORTNIGHTLY Income and Expenditure Continued.

	$
FOOD TOTAL
Groceries/Supermarket
Fruit and Vegetables
Lunches (Work/School)
Takeaway and Eating Out
EDUCATION TOTAL
School Education Fees/Books/Electronics
Uniforms
Self-Education
School Excursions/Camps
Pre-School
Child Care Fees/ Baby sitting
OTHER TOTAL
Superannuation - Self Contributions
Life/Income/Funeral Insurance
Professional/Work/License Fees
Savings
Pet-Vet Fees/Pet Insurance/Medication
Pet Food (from Vet/Pet Shop)
OTHER Expenditure
TRANSPORT TOTAL
Petrol
Repairs/Service/Tyres
Registration
Fines
Car Insurance
Drivers License/HR/MR
Fares (Bus, Train, Uber, Taxi etc)
EXTRAS TOTAL
Home/Household
Therapy
Extra 4
Extra 5
Extra 6
Extra 7
Extra 8

Section 3 Continued

FORTNIGHTLY Income and Expenditure DEBTS

	Creditor Name	Fortnightly Payment	Balance Owing
Creditor 1
Creditor 2
Creditor 3
Creditor 4
Creditor 5
Creditor 6
Creditor 7
Creditor 8
Creditor 9
Creditor 10
Creditor 11
Creditor 12

Fortnightly Expenditure

	$
Living Expenses Total
Creditors/Loan Expenses
Total

Fortnightly Income

	$
Your Work Income
Partner/Spouse Income/Pension
Pension/Benefit
Energy Supplement
Pension supplement
Rent Assistance
Other
TOTAL

Fortnightly Difference

$

Fortnightly Income Minus Fortnightly Expenditure

	$
Fortnightly Income Minus Fortnightly Expenditure

1.       Nature of Our Service

Money Mentors Financial Counselling service is free and confidential and assists consumers to deal with their finances in an effective way. We assist clients to manage their financial situation realistically, to identify the options open to them in their situation, and to weigh the advantages and disadvantages of those options. Our service does not provide legal, or account assistance and it does not lend money.

2.       Your Responsibilities

For us to provide efficient services for you, we request that you:

2.1   Be respectful and considerate towards our staff and other clients. (You may be refused assistance if you attend our service under the influence of alcohol or drugs, or your behavior is aggressive)

2.2   Reply as soon as we contact you.

2.3   Keep us informed of any change in your address or contact details, and any major change in your financial situation.

2.4   Be clear and honest with the information you provide to us about your financial situation. You must give us all relevant and up to date information so we can help you in an efficient way.

3.       Our responsibilities

In return for your co-operation, Money Mentors will:

3.1   Provide you with relevant information and options within the ability of our service, and advise you when you need assistance from another service or person.

3.2   Treat you in a respectful, considerate, and non-discriminatory manner.

3.3   We will keep you informed of any significant changes relevant to your situation.

4.       Confidentiality

While our service maintains confidentiality of our clients and their files in all normal circumstances, it will reveal some information if it is obligated to by the law. Examples of times where it may be necessary to reveal information are, if our service is served with a Subpoena issued by a Court, or if a notice is received from a Government agency. We are also required by our management and funding organisations to collect statistics, and report to those organisations. Our service will also disclose information for the purpose of avoiding the probable commission of a serious offence or for the purpose of preventing imminent serious physical harm to you or to another person.

5.       Privacy

Our service works under the Commonwealth Privacy Act 1988.

During the time, we work with you, it may be necessary for us to collect personal information from you and pass it on to third parties such as creditors and their representatives. By signing this service agreement, you agree to us collecting, using, and passing on your personal information when it is required to provide the best service for you.

Our service has a privacy policy; if you wish to see a copy of it you can contact the management of this service.

6.       Realistic Goals

While our service is happy to work with you towards your goals, it is important you understand we cannot guarantee a specific outcome for you. We ask that you respond within a reasonable time to our letters or phone calls to you. If we do not hear from you within a month, we will assume you no longer want to work with our service, and we will close your file.

7.       Disposal of Files

We shall keep copies of letters and documents we have prepared for you for our own record and keep our diary and file notes that we have made throughout our time serving you.

We retain files for a period of seven years after the file is closed. After this time, the file is destroyed and disposed of in such a way that the privacy of the information is guaranteed.

8.       Agreement

If you wish for Money Mentors to provide you this service, we request that you sign and date your copy of this letter and return it to Money Mentors.

9.       Client Feedback

Money Mentors Financial Counselling Service is committed to making a positive difference in the lives of those we help. To assist us with continuous improvement, we will offer a survey after attending this service. All feedback will remain confidential.

10. Complaints Process

Clients’ feedback including complaints about our services are welcomed. Feedback can be given in writing or verbally and includes the right for you to have an advocate present when making a complaint. Every effort will be made to achieve a successful resolution should you have a complaint.
Client 1- Signature*

Clear
Client 1- Name*

First NameLast Name
Date*

DayMonthYear
Date
Client 2- Signature

Clear
Client 2- Name

First NameLast Name
Date

DayMonthYear
Date
Should be Empty:

	Name	DOB
Child 1
Child 2
Child 3
Child 4
Child 5

FINANCIAL COUNSELLING SERVICE