NAME
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First Name
Last Name
PHONE
*
(###)
###
####
EMAIL
*
What is your current job level?
*
Executive (i.e. VP, CFO, CEO, COO, CIO, etc)
Mid-level Management (Sr. Manager, Director, etc.)
First-level Management (Supervisor, Manager, Department Manager, etc.)
Intermediate /Experienced (Individual contributors with 5+ years of experience)
Entry - level (Individual contributor with less than 5 years of experience)
Which functional area do you currently work in?
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Administration
Finance
Clinical/Medical
Human Resources
Information Technology
Marketing
Operations
Sales
Strategy
Engineering
Research & Development
Customer Service
Business Development
Logistic/Procurement
Other
Which industry do you currently work in?
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Aerospace
Agriculture
Chemical
Commerce
Construction
Consumer Packaged Goods
Education
Energy
Entertainment
Forestry
Food
Government
Healthcare
Hospitality
Manufacturing
Media
Mining
Music
Pharmaceutical
Professional Services
Shipping
Technology
Telecommunication
Textiles
Tourism
Transport
Utilities
Other (please complete field below)
If you chose other for industry, please add industry type here:
What are the coaching topics you want to focus on?
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Please select all relevant topics of interest.
Strategy and strategic thinking
Influence and leadership presence
Building effective teams
Communication skills
Conflict management
Decision making, working with uncertainty and ambiguity
Delegation and empowerment
Developing others, mentoring, succession planning
Interpersonal relationships, listening skills and empathy
Leading during times of change
Motivation and engagement, leading with vision and purpose
Organization, resource management and task completion
Self-awareness
Time and energy management; organization
Are there other coaching topics not listed above you want to focus on?
What are the top three interpersonal attributes you would like your coach to possess?
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Please select three.
Building trust
Collaborating and working well together with others
Comforting people when they need it
Clear communication skills
Conflict management and resolution skills
Constructive feedback (ways people can improve)
Diplomacy (handling affairs without hostility)
Caring about other people
Driven; results oriented
Empathy for others
Encouraging and inspiring people to do their best
Flexibility in thinking and operating style
Humor and lightheartedness
Inspiring and motivating
Listening well
Networking and building relationships; Socializing skills
Patience when dealing with others
Public speaking and presentation skills
Self-awareness
Sensitivity toward the preferences and wishes of others
Tolerance and respect for others
Are there interpersonal attributes not listed above you want your coach to possess?
Are there any life experiences that you feel are important for your coach to have?
Are there any demographics that you feel are important for your coach to possess?
If you have a coach preference at this time, please write their name below: