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Coaching Intake Form
Power
Up
Leadership
Thank you for taking a moment to fill out our intake form. We’d like to get to know you better so we can create the best coaching plan for you.
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Name
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First
Last
Phone
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Email
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Company
Current Position
In just a few sentences, tell us a bit about your personal/professional life. Who are you/what do you do?
Have you ever worked with a coach before?
Yes
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Your Leadership Strengths & Goals
I have read the instructions clearly.
Please rate your current performance from 1 to 10 in the following leadership competencies (1 = Needs improvement, 10 = One of your strengths):
Wellness: Energy level tapped into from priming the body through physical activity, nutrition, and rest.
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Wellness: Mindfulness achieved through meditation, reflection, and creating inner calm.
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Wellness: Social connections resulting in emotional support and sense of belonging.
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Mindset: Stress management mindfulness practices are in place to boost resilience to bounce back from stress.
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Mindset: Ability to identify and reframe self limiting beliefs to embrace a growth mindset.
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Mindset: Feeds the brain new knowledge to foster ongoing learning and development each day.
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Self Awareness: Has clear understanding of one's own strengths and weaknesses.
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Self Awareness: Clarity on your most important professional and personal goals and values.
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Self Awareness: Takes time to reflect on performance and leadership behaviours to further self understanding and lessons learned.
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North Star Purpose: Articulates compelling why and purpose behind the work.
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North Star Purpose: Shows high agility in responding to new opportunities whether internally or externally driven.
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North Star Purpose: Makes connections between organizational functional areas to see how different priorities fit together.
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Strategic Plan: Goals for the month, quarter, year are clearly understood and written down.
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Strategic Plan: Engages key partners and team for input to refine and execute strategic goals and objectives.
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Strategic Plan: Performs review of operational plan against annual strategy to ensure alignment.
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Leadership Presence: Communicates with energy, edge, emotional intelligence, and passion in all interactions.
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Leadership Presence: Awareness of eye contact, hand gestures, tone, and body language.
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Leadership Presence: Share personal stories and forge emotional connection with audience to motivate and engage.
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Leadership Presence: Lead assertively, especially during times of uncertainty and change.
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Courageous Authenticity: Challenge the status quo and speak the truth to internal and external audiences.
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Courageous Authenticity: Shows up as a real authentic human reflecting the leader’s true personality, style and opinions.
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Empathy: Adapt tone to fit the situation to communicate with care, putting yourself in audience's shoes to best adapt the message and tone for the audience receiving the message.
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Empathy: Fit key mesages to best fit audience's knowledge level, style and areas of interest and concern.
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Engages in High Stakes Conversations: Asks powerful questions to understand other's interests.
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Engages in High Stakes Conversations: Actively listens before responding.
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Engages in High Stakes Conversations: Able to directly challenge, and clearly state one's own interests and reach agreement with others.
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Integrity: Demonstrate behaviours that align with the organization’s values and purpose.
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Integrity: Communicate with authenticity and honesty across all audience groups.
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Integrity: Willing to take bold stands on difficult issues as required.
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Relationship Building: Prioritize getting to know each member of the team to foster stronger relationships.
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Relationship Building: Build caring connections to best serve each team and individual you interact with.
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Relationship Building: Forges internal and external connections to build network and relationships among team and community.
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Coaching: Identifies and embraces coachable moments to coach team to build skills, knowledge, and leadership capability.
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Coaching: Seeks out internal coaching for yourself as a leader from your peers or other key team members.
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Empowerment: Delegate responsibilies to team members to empower them to own and take accountability for their work.
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Empowerment: Delegate and trust team members to plan work and take accountability for achieving results.
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Empowerment: Encourage team members to make decisions and set direction for their own work in alignment with department plan.
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Recognition: Express appreciation for results achieved by direct reports, peers, and senior management.
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10 (One of my strengths)
Recognition: Express appreciation for results achieved by direct reports, peers, and senior management.
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Disciplined Focus: Unrelentless commitment to take consistent action to achieve goals.
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Disciplined Focus: Focus efforts on areas that play to your strengths.
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Collaboration: Solve problems by collaborating with experts and team members across functional areas.
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Collaboration: Actively seek out input from others to engage team participation.
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Which of these areas would you like to focus on with a coach? Select all that apply.
Energy and Mindset Booster: Health & Wellness
Energy and Mindset Booster: Mindset
Energy and Mindset Booster: Self Awareness
Clear Strategic Focus: Strategic Plan
Clear Strategic Focus: North Star Purpose
Masterful Communicator: Courageous Authenticity
Masterful Communicator: Empathy
Masterful Communicator: Leadership Presence
Strong Influencer: Relationship Builder
Strong Influencer: Integrity
Strong Influencer: Engages in High Stakes Conversations
Team Alignment: Recognition
Team Alignment: Empowerment
Team Alignment: Coaching
Consistent Execution: Disciplined Focus
Consistent Execution: Collaboration
Other
If you selected 'Other' focus area, please specify:
Lastly, what are you looking to get out of your coaching experience? What would you like to see from your ideal coach?
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