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Coach Request Form

Please complete the following form as thoroughly as possible. All information provided will be kept in strict confidentiality. The questions are designed to help us understand the background and specific coaching objectives regarding the person in need of coaching, and will help us select the most appropriate coach from our network.
Person completing the form:
1.First name
2.Last name
3.Position
4.Company
5.Email Address
6.Contact Number
Person to be coached (Coachee):
7.First name
8.Last name
9.Position
10.Company
11.City and country where coachee is located
12.Email Address
13.Contact Number
14.Coaching has already been approved by the company:
15.The coachee is aware that coaching is being sought:
16.If yes, what is the coachee’s attitude and interest in being coached?
17.The coachee is seen by the company as (select all that apply):
18.Budget allocated for the coaching program:
19.Please provide discount code if applicable
20.If you filed a claim with your health insurance provider, how happy are you with the outcome?
21.Main coaching theme(s):
22.The coachee has received coaching in the past:
23.If yes, what were the results of this coaching experience?
24.What assessment results are already available for this coachee, if any? Please select all that apply
25.Direct supervisor’s desired/planned involvement in the coaching:
26.Company’s involvement in the coaching:
27.Desired starting date of the coaching relationship:
28.Frequency of the coaching sessions:
29.Number of coaching sessions:
30.Duration of coaching relationship:
31.Desired coaching medium:
32.Preferred location, in case of face-to-face coaching:
33.Preferred coaching style:
34.Preferred gender of coach:
35.Desired background and experience of coach (if any):
36.Preferred coaching language(s):