EmailMe Form - Coaching Registration & Client History

Coaching Registration and Client History

Please complete this form to begin your engagement with our coaching practice. Doing so does not obligate you in any way. You may opt to save your answers and complete the form within three days. Please see the Save and Resume link at the bottom of this page.

If you were referred by someone, please provide this person's name:

I understand that my information will be kept confidential: *

Yes

Name: *

First Last

Nickname:

If other than your first name, how would you like to be addressed?

Occupation: *

Years in occupation: *

Employer: *

For what organization are you currently employed:

Years at current employer: *

Position/Job Title: *

For what organization are you currently employed:

Email: *

Confirm Email:

Mobile Phone: *

### - ### - ####

If necessary, may we reach you by text message at your mobile number? *

Yes

No, I prefer my professional email

No, I prefer my personal email

Other - I will explain

Alternate Phone:

### - ### - ####

Mailing Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Partnership Status: *

Number of Children: *

Your Motivations

Please give us a sense of why you think coaching might be beneficial for you?

Don't count the stars, but simply use your gut to rate the importance or applicability of each factor:

I have one or more attractive opportunities: *

I am confronting one or more challenging circumstances: *

I want to understand myself and my tendencies better: *

I want to better understand and navigate certain situations: *

I want to be more intentional about setting goals or being more strategic: *

What are some specific benefits you hope to gain? Select the top three most relevant to you:

What level of stress, pressure, or frustration do you experience on a regular basis in your PERSONAL life? *

What level of stress, pressure, or frustration do you experience on a regular basis in your PROFESSIONAL life? *

Do you care for an elderly person or someone with a serious illness or disability? *

In the last 12 months, have you had any adverse action taken against you by your employer? *

How often do you cope with feelings of frustration, anger, disappointment, or other negative feelings about your career? *

Which of the following assessments have you taken in the past? *

If you know any of your results from the above assessments, please share below:

Which of the following statements do you find most accurate or most applicable to you: *

I like results. I want to accomplish important goals and get things done.

I like influencing. I want to impact people and affect the conditions in which they work.

I like people. I want connection and good relationships.

I like the possibilities. I want to think about the steps and choices that will lead to success.

In thinking about how you like to learn or process information with others, where would you place yourself on the following continuum - Listening and Reflection (1) vs. Expression and Discussion (10):

Was coaching recommended or required by a supervisor or manager? *

Recommended

Required

Neither

How urgent is growth or self-improvement for you right now? *

Very - I'm under immediate pressure to get results

Generally - I have a lot to gain or lose

Somewhat - I'm not under any pressure but I'd like some things to be better

Not at all - I'd just like to see what's possible for me

Do you have access to a private location where you can comfortably participate in a coaching call? *

Which of the following video platforms are you able to use or access from your computer or mobile device: *

Personal Narratives

Please take a few minutes to answer the following questions to help your coach learn more about you. You have a maximum of 100 words per answer.

Please remember that your answers are confidential. The more you are willing to share, the more you can be supported in accomplishing your goals.

How are things currently going for you in your career - what is going well and what do you wish was going a bit better? *

Describe any serious personal or professional hardships that you are coping with right now (optional):

What are your hopes and goals for the next five years? *

Please share anything else about yourself or your goals that you think are relevant:

File Upload

The following are optional but helpful to your coach.

Optional: Please upload a copy of your resume, CV, or a professional statement of qualifications.

Optional: Please upload a quality headshot photo of yourself taken recently:

Your photograph will not be shared, and is used only as part of our coaching records.