Rehab Management's Mental Health & Wellbeing Screen

Welcome to Rehab Management's Mental Health & Wellbeing Screen. Your health is important to us, so we request that all information is filled out to the best of your ability. This will assist us to guide any future coaching program.

We hold all your responses in the strictest of confidence. At Rehab Management we aim to build trust through meaningful interactions and we look forward to reviewing your results upon completion of the screen.

Please read each statement and enter a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week.

There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0 - Did not apply to me at all
1 - Applied to me to some degree, or some of the time
2 - Applied to me to a considerable degree or good part of time
3 - Applied to me very much or most of the time

All fields marked with an * are mandatory.

Completion of the screen will only occur once you click the submit button. If you decide not to finish and/or not to submit the screening your responses will be lost and deleted from the system.

First Name*

Last Name*

Gender*

Department*

Location*

NorthNorth-West / WestSouth

Please input a valid mobile number and click Confirm. A SMS validation code will be sent to your mobile. Enter the validation code and click Confirm.

Mobile Phone Number *

Mobile Phone Number*

Do not add '0' - Do not use SPACES e.g. +61444444444

Please ensure the phone number does not start with a '0' (zero) e.g. +61444444444

Preferred Email Address

example@example.com

Work Email*

Date of Birth

Date