Ponsonby Rugby
Wellbeing Check In
Name
First Name
Last Name
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I am happy with my current physical condition
*
Strongly Disagree
1
2
3
Strongly Agree
4
1 is Strongly Disagree, 4 is Strongly Agree
What is working well for you?
What concerns do you have?
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I am performing well at work and/or in my studies
*
Strongly Disagree
1
2
3
Strongly Agree
4
1 is Strongly Disagree, 4 is Strongly Agree
What is working well for you?
What concerns do you have?
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I am connected to my friends
*
Strongly Disagree
1
2
3
Strongly Agree
4
1 is Strongly Disagree, 4 is Strongly Agree
What is working well for you?
What concerns do you have?
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I am happy in my current bubble
*
Strongly Disagree
1
2
3
Strongly Agree
4
1 is Strongly Disagree, 4 is Strongly Agree
What is working well for you?
What concerns do you have?
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I'm satisfied with where I am at
*
Strongly Disagree
1
2
3
Strongly Agree
4
1 is Strongly Disagree, 4 is Strongly Agree
What is working well for you?
What concerns do you have?
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Would you be interested in online education/workshops around up skilling or personal development?
*
Yes
No (go to next page)
Maybe
If so would you prefer
Morning
Afternoon
Evening
Weekend
What time would suffice?
25 mins
35 mins
45 mins
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Do you have any further comments?
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