Online assessment
This questionnaire will help us register you for one of our change4life programs. All responses will be kept confidential and will be used solely for the Program. Please provide responses to all questions so that we can properly complete the assessment process.
Feel free to contact us by phone on (03) 9369 6873 if you'd prefer to complete your registration over the phone.
* Required
Email address
*
Your email
CONTACT DETAILS
Name:
*
Your answer
Phone number:
*
Your answer
QUESTIONNAIRE
Which program are you interested in?
*
Youth Program
Online Program
Residential Program
Required
1. Have you been struggling with life?
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Yes
No
2. What are your main life challenges?
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Your answer
3. Are you connected with any other agency/support service?
*
Yes
No
4. If yes, please provide details (agency/support service name, case worker/primary contact name and phone number).
*
Type 'N/A' if your response to question 3 is 'No'.
Your answer
5. Do you receive Centrelink benefits?
*
(Note: if you don't receive benefits but are eligible, you will need to contact Centrelink to apply for an allowance prior to admission)
Yes
No
6. Do you have a Medicare card?
*
(If you don't, you''ll need to apply for one prior to admission)
Yes
No
7. This is a faith/spiritual-based program - are you comfortable with this?
*
Yes
No
8. Are there any other comments that you would like to add?
Your answer
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