This intake form helps us understand your circumstances and how we may be able to assist you. Completing the form as accurately and thoroughly as possible will help us assess your support needs more quickly and reduce delays in providing assistance. First Name Preferred Name Leave blank if none Middle Name Leave blank if none Last Name What are your pronouns? What is your gender? Do you identify as Aboriginal or Torres Strait Islander? Do you identify with any particular culture or cultural background? (Please select) Unknown Aboriginal Acehnese Acholi Afghan African American Igbo Afrikaner Akan Albanian Algerian American Amhara Anglo-Burmese Anglo-Indian Angolan Arab, nec Argentinian Armenian Assyrian Australian Australian South Sea Islander Austrian Azeri Bahraini Balinese Bangladeshi Barbadian Bari Basque Batswana Belarusan Belgian Bengali Berber Bermudan Bhutanese Bolivian Bosnian Brazilian British, nec Bruneian Bulgarian Burgher Burmese Burundian Cameroonian Canadian Caribbean Islander, nec Catalan Central American, nec Central and West African, nec Central Asian, nec Chaldean Channel Islander Chilean Chin Chinese Chinese Asian, nec Colombian Congolese Cook Islander Coptic Costa Rican Croatian Cuban Cypriot Czech Danish Darfur Dinka Dutch Eastern European, nec Ecuadorian Egyptian Emirati English Eritrean Estonian Ethiopian Fijian Fijian Indian Filipino Finnish Flemish French French Canadian Frisian Fulani Georgian German Ghanaian Gibraltarian Gio Greek Guatemalan Gujarati Guyanese Hawaiian Hazara Hispanic North American Hmong Hungarian Hutu Icelandic I-Kiribati Indian Indian Tamil Indonesian Iranian Iraqi Irish Italian Ivorean Jamaican Japanese Javanese Jewish Jordanian Jordanian 1,180 Kadazan Karen Kashmiri Kazakh Kenyan Khmer (Cambodian) Korean Krahn Kunama Kurdish Kuwaiti Kyrgyz Lao Latvian Lebanese Liberian Libyan Lithuanian Luxembourg Macedonian Madi Madurese Mainland South-East Asian, nec Malawian Malay Malayali Maldivian Maltese Mandaean Mandinka Manx Maori Maritime South-East Asian, nec Masai Mauritian Mayan Melanesian and Papuan, nec Mexican Micronesian, nec Moldovan Mon Mongolian Montenegrin Moroccan Mozambican Namibian Native North American Indian Nauruan Nepalese New Caledonian New Zealander Nicaraguan Nigerian Niuean Ni-Vanuatu Norfolk Islander North American, nec Northern European, nec Norwegian Nubian Nuer Ogaden Omani Oromo Other North African and Middle Eastern, nec Other North-East Asian, nec Pakistani Palestinian Papua New Guinean Paraguayan Parsi Pathan Peoples of the Sudan, nec Peruvian Pitcairn Polish Polynesian, nec Portuguese Puerto Rican Punjabi Qatari Rohingya Roma Gypsy Romanian Russian Rwandan Salvadoran Samoan Saudi Arabian Scottish Senegalese Serbian Seychellois Shona Sierra Leonean Sikh Sindhi Singaporean Sinhalese Slovak Slovene Solomon Islander Somali Sorb/Wend South African South American, nec South Eastern European, nec South Sudanese Southern and East African, nec Southern Asian, nec Southern European, nec Spanish Sri Lankan Sri Lankan Tamil Sudanese Sundanese Swahili Swazilander Swedish Swiss Syrian Tahitian Taiwanese Tajik Tamil, nfd Tanzanian Tatar Telugu Temoq Thai Themne Tibetan Tigrayan Tigre Timorese Togolese Tokelauan Tongan Torres Strait Islander Tunisian Turkish Turkmen Tuvaluan Ugandan Uighur Ukrainian Uruguayan Uzbek Venezuelan Vietnamese Vlach Welsh Western European, nec Yemeni Yezidi Yoruba Zambian Zimbabwean Zulu Trinidadian Tobagonian Country of birth What type of visa do you hold? Refugee/Humanitarian Visa (e.g. 200, 204, SHEV, TPV) Bridging Visa Unknown (Please select) Australian Citizen Permanent Resident (PR) Temporary Visa – Student Temporary Visa – Tourist Temporary Visa – Working Holiday Temporary Visa – Partner Temporary Visa – Skilled Worker (e.g. 482, 457) If applicable, what year did you arrive in Australia? Main language spoken at home Other languages spoken How would you rate your English reading and writing skills? (Please select) Very well Well Not well Not at all Unknown (Not Stated/Not adequately described) How would you rate your English speaking skills? (Please select) Very well Well Not well Not at all Unknown (Not stated/Not adequately described) Do you need an interpreter? (Please select) No Yes (spoken language other than English) Yes (non-spoken communication) Unknown (Not Stated) Do you live with any disability? (Please select) Speech Intellectual Physical Psychological Acquired Brain Injury Developmental Hearing Neurological (including Epilepsy and Alzheimer's disease) Vision Chronic health condition Other None Not Stated Unknown Yes - undisclosed If you selected 'Other', please specify Disability Do you identify as part of the LGBTQIA+ community? (Please select) Yes No Not specified Unknown Current relationship status (Please select) Divorced Married or defacto Separated Unknown (Not Stated/Not adequately described) Widowed Single In a relationship (not defacto) Are you currently in custody? (Please select) Yes No Unknown At Risk What is the safest way to contact you? (Please select) Phone Call Voicemail SMS Mail Email Video Call What is the safest time to contact you? Were you referred to us by somebody? Leave blank if unsure Do you consent to us sharing your information between our team (lawyer, financial counsellor, social worker) to help support you? (Please select) Yes No N/A Employment status (Please select) Employed Unemployed Self-employed Retired Unknown Other Type of work (Please select) Paid work full-time Paid work full-time and second job Paid work part-time Paid work casual Unpaid Work N/A What is your main income source? (Please select) Government pension, benefit or allowance (eg family payment, rent assistance, age pension etc) Employee Income Unincorporated business income Income source Other (e.g informal payments, board, prize money) Transport Accident Commission (TAC) payment Income protection Total and Permanent Disablement Payment No Income Not stated Other (see notes below) Individual income (per fortnight) Individual income (yearly) Total household income (per fortnight) Total household income (yearly) Please describe all sources of household income (including other people contributing, their jobs, and employers if known) Do you receive any Centrelink benefits? (Please select) ABSTUDY Age Pension Austudy Carer Payment Disability Support Pension Family Tax Benefit Jobkeeper Jobseeker No Other (see notes below) Paid parental leave Parenting Payment Sickness Allowance Special Benefit SRSS payment Unknown Veterans benefit Youth Allowance When did your Centrelink card start? When does your Centrelink card expire? What is your CRN? "N/A" if not applicable How much do you have in savings? If unsure, write 'N/A' Superannuation details Please include the company name, balance, and any benefits Do you have any other debts? If none, write 'N/A' What is your household arrangement like? (Please select) Two parent family with dependent children Sole parent family with dependent children Not living in a family (eg living as boarder, in shared house, alone, in hostel, boarding house etc) Family type Other Multiple Families Couple Co-ownership (owners not related) Not stated How many people live in your household? How many dependent children do you have? How many other dependents do you have? Please list the names and dates of birth of your dependents: If not applicable, simply write "N/A" Type of housing (Please select) Community Housing Crisis Accommodation Homeless Living With Family Transitional Housing Resides in their own mortgaged property Owns home outright Private Tenancy Sublet or Licensee Rooming House Caravan Park Part 4A Site Other/Not specified Public Housing Local council area (LGA) of your property (Please select) Alpine (Rural) Ararat (Rural) Ballarat (Outer/Peri-Urban) Banyule (Metro and Inner Urban) Bass Coast (Outer/Peri-Urban) Baw Baw (Rural) Bayside (Metro and Inner Urban) Benalla (Rural) Boroondara (Metro and Inner Urban) Borough of Queenscliffe (Rural) Brimbank (Outer/Peri-Urban) Buloke (Rural) Campaspe (Rural) Cardinia (Outer/Peri-Urban) Casey (Outer/Peri-Urban) Central Goldfields (Rural) Colac Otway (Rural) Corangamite (Rural) Darebin (Metro and Inner Urban) East Gippsland (Rural) Frankston (Outer/Peri-Urban) Gannawarra (Rural) Glen Eira (Metro and Inner Urban) Glenelg (Rural) Golden Plains (Rural) Greater Bendigo (Outer/Peri-Urban) Greater Dandenong (Outer/Peri-Urban) Greater Geelong (Outer/Peri-Urban) Greater Shepparton (Rural) Hepburn (Rural) Hindmarsh (Rural) Hobsons Bay (Outer/Peri-Urban) Horsham (Rural) Hume (Outer/Peri-Urban) Indigo (Rural) Kingston (Outer/Peri-Urban) Knox (Outer/Peri-Urban) Latrobe (Rural) Loddon (Rural) Macedon Ranges (Rural) Manningham (Outer/Peri-Urban) Mansfield (Rural) Maribyrnong (Metro and Inner Urban) Maroondah (Outer/Peri-Urban) Melbourne (Metro and Inner Urban) Melton (Outer/Peri-Urban) Merri-bek (Metro and Inner Urban) Mildura (Rural) Mitchell (Rural) Moira (Rural) Monash (Outer/Peri-Urban) Moonee Valley (Metro and Inner Urban) Moorabool (Outer/Peri-Urban) Mornington (Outer/Peri-Urban) Mount Alexander (Rural) Moyne (Rural) Murrindindi (Rural) Nillumbik (Outer/Peri-Urban) Northern Grampians (Rural) Port Phillip (Metro and Inner Urban) Pyrenees (Rural) South Gippsland (Rural) Southern Grampians (Rural) Stonnington (Metro and Inner Urban) Strathbogie (Rural) Surf Coast (Rural) Swan Hill (Rural) Towong (Rural) Wangaratta (Rural) Warrnambool (Rural) Wellington (Rural) West Wimmera (Rural) Whitehorse (Outer/Peri-Urban) Whittlesea (Outer/Peri-Urban) Wodonga (Rural) Wyndham (Outer/Peri-Urban) Yarra (Metro and Inner Urban) Yarra Ranges (Outer/Peri-Urban) Yarriambiack (Rural) Street address of your mortgaged property Suburb Post code State (Please select) VIC NSW QLD SA WA TAS NT ACT Do you own more than one property? (Please select) Yes No Unsure Name of your mortgage lender Did you use a mortgage broker? If yes, who? Who is listed on the mortgage (including guarantors or co-borrowers)? Who is listed on the property title? Purchase price of mortgaged property Settlement date of purchased property When did your current mortgage start? How much did you originally borrow? If unsure, simply write 'unsure' Current value of property Leave blank if unsure Where did you get this valuation from? (Please select) Client Estimate Real Estate Agent appraisal/estimate Bank Valuation How much do you currently owe on your mortgage? If unsure, simply write 'Unsure' Current interest rate (%) Interest type (Please select) Variable Fixed Variable + Fixed Unsure Have you recently come off a fixed rate? (within the last 6 months) Not Collected Unsure NO YES Current structure of mortgage repayments (Please select) Principal + Interest Interest only Unsure How much are your repayments? How often do you make repayments? (Please select) Weekly Fortnightly Monthly Bi-monthly Quarterly Other / Not specified When did you last make a payment? Do you currently have any arrears? Are you currently on a hardship arrangement (or are awaiting the outcome of one)? (Please select) Yes No Unsure Do you have home/building insurance? (Please select) Yes No Unsure Do you have mortgage or loan protection insurance? (Please select) Yes No Unsure What factors have contributed to your mortgage stress? (Select any that apply or describe your situation) (Please select) Building Issues Alcohol, drug or substance use COVID-19 Domestic and Family violence (Victim/Survivor) Elder abuse Employment difficulties Gambling Incarceration Interest rate rise Irresponsible lending Mental health Natural disaster inc. climate change Other Other debts Personal Accident / Injury Physical health / medical issues Relationship / family breakdown Unemployment TAC/Workcover etc. payout pending Other contributing factors not listed How would you rate your overall health? (1–10) (Please select) Unable to answer 1. (not healthy at all) 2. (extremely low health) 3. 4. (low health) 5. 6. (moderate) 7. 8. (high health) 9. 10. (extremely high health) "Healthy" is whatever it means to you. How would you rate your current stress level? (1–10) (Please select) Unable to answer 1. (no stress) 2. (extremely low) 3. 4. (low) 5. 6. (moderate) 7. 8. (high) 9. 10. (extremely high) 1 being lowest, 10 highest Do you feel safe at the moment, or is your mortgage stress affecting your safety? Are you currently experiencing family violence, or have you experienced it in the past and it is still affecting your situation? (Please select) N/A A victim/survivor A perpetrator of family violence Are you receiving support from any other services? If so, please specify What kind of help are you looking for from us? (e.g. keep your home, sell your home, urgent assistance, legal advice)
