Ready Set Go check In

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Thank you for participating in the ReadySetGo! program brought to you by Back2Work and Humanity Code, part of the Humanity Health Group.

This check-in assessment asks how you feel about your quality of life, health, or other areas of your life. This will help our team be mindful of your circumstances throughout the program. If you are unsure about which response to give to a question, please choose the one that appears most appropriate. This can often be your first response. Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the last two weeks.

If you have any questions, please ask your Facilitator on Day 1 of the program.
READ OUR PRIVACY STATEMENT HERE

Your Personal Details

Who is your Employment Provider?*

What is your name?*

Your email?*

Your gender?*

Female
Male
Non-binary

Your date of birth*

What is your highest education reached?*

Primary School
Secondary School
Tertiary (TAFE, University, etc)

What is your relationship status?*

Are you currently ill?*

Yes
No

What illness/es are you experiencing?

Your Quality of Life

This quality of life assessment asks how you feel about your quality of life, health, and other areas of your life. Some questions may feel intrusive and personal, but they help provide a full picture of your circumstances. If you are unsure about which response to give to a question, please choose the one that appears most appropriate. This can often be your first response. Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the last two weeks.THIS INFORMATION IS NOT SHARED WITH ANY THIRD PARTIES.

How would you rate your quality of life?*

In the last 2 weeks, how satisfied are you with ...*

We understand these two questions may feel intrusive and personal, but they help provide a full picture of your circumstances.

In the last 2 weeks, how satisfied are you with ...*

	Very dissatisfied	Dissatisfied	Neither dissatisfied nor satisfied	Satisfied	Very satisfied
The support you get from your friends?
The conditions of your living place?
Your access to health services?
Your mode of transport?

How often do you have negative feelings such as blue mood, despair, anxiety or depression?*

READYSETGO CHECK-IN

Thank you for participating in the ReadySetGo! program brought to you by Back2Work and Humanity Code, part of the Humanity Health Group.

Your Personal Details

Your Quality of Life

Request a call back

READYSETGO CHECK-IN

Thank you for participating in the ReadySetGo! program brought to you by Back2Work and Humanity Code, part of the Humanity Health Group.

Your Personal Details

Your Quality of Life

Your Privacy

Request a call back