Leadership Coaching Intake Question Title * 1. Please provide the following information about yourself: First Name Last Name Email address Question Title * 2. What is your current leadership role? Vice President MSA President AMAC Chair Senior Medical Director Regional Medical Director Regional Program Medical Director Medical Director Associate Medical Director Regional Department Head Department Head Associate Department Head Division Head Associate Division Head Program Head NP Executive NP Lead Site Lead Physician/Medical Lead Committee Chair Other (please specify) Question Title * 3. How long have you been in your current VCH/PHC leadership role? 0-3 years 3-5 years 5-10 years 10+ years Question Title * 4. What is your practice type? Dentist Midwife Nurse Practitioner Physician Question Title * 5. What specific challenges/goals do you want to tackle/achieve through coaching? Question Title * 6. Do you have prior experience being coached? No If yes, please elaborate: Question Title * 7. What is fundamentally important to you in the coaching relationship/experience that we should be aware of? Question Title * 8. Which day(s) of the week would be most suitable for a 1 hour coaching call? Monday Tuesday Wednesday Thursday Friday Question Title * 9. What time(s) of the day would be most suitable for a 1 hour coaching call? Question Title * 10. Is there anything else you would like to mention about yourself or your expectations from coaching? Done
