Please provide the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Coach & Client Confidentiality

The issue of confidentiality is paramount to this relationship.  My understanding is that nothing in this relationship is to be discussed outside of our conversations.  There are times when references to others may be helpful, however I would not ever mention a name or person that would lead someone to infer the discussion was about you as a client. I also expect that you will say nothing about what I talk about as well in the relationship without expressed permission. However, I am bound by law to report any criminal act or violation of your company's policy to your sponsor.

PLEASE indicate your comfort level with this level of confidentiality and express your concerns in the space below if the above stipulation is insufficient to assure comfort.

Reason for Coaching

List in as few a words as possible the specific reason you chose coaching:

 Please write up to 250 words explaining what you would like to target in the next 13 weeks as a specific result you would like to have from the coaching:

At what level in organizations have you worked before:

Enterprise Level [C Level, or MD level]
Group Level [Senior VP]
Business Unit Level [VP, MD, GM]
Functional Level [VP]
Managerial Level
Supervisory Level

Other

If other:

Please choose the highest U.S. dollar level correlated to a budget you oversaw:

<1 million
1-5 million
5-10 million
100 million
500 million
1 billion
>1 billion

Have you completed any of the following assessments:

(Check all that apply)

Representational Styles [Visual, Auditory, Kinesthetic, Auditory Digital]
Managing for Success: Personal Interests Attitudes & Values
Managing for Success; DiSC or equivalent
Myers-Briggs: If yes, please enter 4 letter type
Myers-Briggs Step II
Reiss Profile of Motivational Sensitivity
Change State Indicator
Thomas-Kilmann Conflict Mode
Kolb Learning Styles
Personal Values Quotient
Kolbe Connative Index
Birkman
Other

If other:

Delivery of Coaching

How would you like to receive feedback, inquiry, challenges and ideas in the coaching?

Strategic Information:

List your strengths:

List your limitations:

List the opportunities you feel you have:

List any threats you feel are present now:

List or describe the values that you honored in the past:

Since these values are about the past, are there new values you aspire to?

Describe your vision of the future:

List all the cliché’s/axioms in your life regarding your guiding principles:

(In other words, what statements of principle do you live your life by?

Examples:

Treat others the way that you would want to be treated
People are right until proven guilty
I don’t trust anyone, they have to earn my trust
 

List 1 Strategic Direction for each of the following areas of your life or business, or both:
 
PERSONAL:

BUSINESS:

List the goals or ideas about the future you have currently around being, doing, having, and becoming over the next 3-6 months:

List the goals or ideas about the future you want to accomplish or be in the next two years:

List the goals or ideas about the future you want to accomplish or be in your lifetime:

What style of coach do you prefer? (gentle, challenging, provocative, direct, indirect, etc.)

If there was anything you could change in your life right now, and there were no constraints on anything, what would you change now:

Describe what it's like when you're at your best:

Any comments you'd like to share:

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