Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Have you worked with a coach before? *

Yes

No

Are you currently working with a therapist or counselor? *

Yes

No

Do you work in education? *

Yes

No

If you work in education, please rate your current level of satisfaction and success in creating your ideal CLASSROOM (physical space). *

5 (highest)

4

3

2

1 (lowest)

Not Applicable

If you work in education, please rate your current level of satisfaction and success in mastering and delivering your CONTENT (instruction and curriculum). *

5 (highest)

4

3

2

1 (lowest)

Not Applicable

If you work in education, please rate your current level of satisfaction and success in your relationships with COLLEAGUES (other teachers, staff members, and administrators). *

5 (highest)

4

3

2

1 (lowest)

Not Applicable

If you work in education, please rate your current level of satisfaction and success in your relationship with your COMMUNITY (students and parents). *

5 (highest)

4

3

2

1 (lowest)

Not Applicable

If you work in education, please rate your current level of satisfaction and success with investing time and energy into your external CURIOSITY (hobbies, passions, and interests outside of education). *

5 (highest)

4

3

2

1 (lowest)

Not Applicable

Which descriptors best fit your desired way to receive feedback? *

Direct

Actionable

Gentle