Refer a Customer to the
Economic Mobility Program at
Crisis Assistance Ministry
Who can we thank for this referral?
Your Name (first and last)
Your Employer's Name
Your Department (if applicable)
Your Phone Number
Your Email Address
Is the customer a permanent resident of Mecklenburg County?
Yes
No
Is the customer the main/joint financial decision maker in their household?
Yes
No
Is the customer having difficulty paying for rent, mortgage, basic utility, or other necessary expenses, OR have they had difficulty doing so within the last 6 months?
Yes
No
Which of the following best describes the customer's current employment situation?
Please select...
Working
Not working but about to start a job
Not working but looking for a job
Not working and not looking for a job (e.g., disabled or retired)
Not working due to temporary condition (e.g., my health)
Which of the following are challenges to improving the customer's financial situation?
The costs of caring for their children or childcare
Finding affordable housing
Finding a good-paying job
Their health
None of these
Current Household Income (monthly)
Current Household Expenses (monthly)
CALC Gap in Income and Expense (monthly)
Would the customer describe his/her income as stable or unstable?
Please select...
Stable
Unstable
No income
Does the customer feel he/she can build savings with his/her current level of income?
Please select...
Yes
No
No income
Has the customer expressed a desire to make changes to their financial life OR learn about budgeting, saving, or other money management skills?
Yes
No
Is the customer open to receiving a call from you and one of our Economic Mobility Specialists to learn about financial coaching services
?
Yes
No
Based on your response to this question, the customer does not seem like a good fit for the Economic Mobility Program at Crisis Assistance Ministry.
Customer Information
Customer's Name (first and last)
Customer's Phone Number
Customer's Alternate Phone Number
Customer's Email Address
Contact Information