First Name(s) (*)
Last Name
Date of Birth
GenderMaleFemaleOtherPrefer not to say
Phone (mobile)
Phone (home)
Ethnicity
Iwi
E-mail (*)
Address
Main source of income (select one)Wages/SalaryBenefitOther
If other type of income, please enter here:
Partner’s first name(s)
Partner’s last name
Partner’s address (if different from above)
Housing type (select one)Renting or flattingOwn home with mortgageSharing housing/boardingRenting to Housing NZOwn FreeholdOther
If other housing type please enter here:
Ages of other people in the house
Previous budgeting advice? (Select one)YesNo
If yes, who with?
Goals you wish to achieve with budgeting?
Client waiver (I agree …)I agree with the below statement: In accordance with the Privacy Act 2020, I understand that this information is to be recorded. It has also been explained to me that my file may be inspected by a representative of our contract provider/s for the purposes of a quality review of this service. I understand that in rare cases the Ministry of Social Development may request my file be transferred to either themselves or another budgeting provider.
Today’s Date
