Laurence Boldt is now accepting applications for a limited number of coaching clients. If you would like to work with Laurence and are a highly-motivated, service-oriented individual who is ready to embrace change and do the work necessary to create the life you want, fill out the questionnaire below. Once received, you will be contacted with further information.

Name:

Current Occupation (if any):

Email Address:* required

Phone: Work Phone:

Cell Phone: Fax:

Home Address:

City/State/Zip:

Mailing Address (if different):

What is the highest level of education you have completed? Please specify the
subject area(s) studied and diplomas or degrees earned, if applicable.


Please answer the following questions. If you are not currently working, please skip to question #9.

1) How many hours per week do you currently spend at work?
20 or less 20-30 30-40 40-50 50-60 60+

2) Briefly describe your work history, paying particular attention to your three
most recent positions.


3) How did you go about selecting the career you are currently in? Briefly describe:


4) What are the three things you like most about your current occupation?


5) What are the three things you like least about your current occupation?


6) What are your main interests outside of your current work?


7) Would you like to stay in the same general career field?
Yes No

8) If yes, what changes would you like to make? (For example, same field
but self-employed, same field but a position with more responsibility,
same general field but specializing in a particular area, etc.)


9) Do you have an idea of what careers you might be interested in?
Yes No

10) If yes, describe:


11) If money or re-training was not an issue, what work would you be
doing right now?


12) What are your primary goals in seeking coaching? What, more
than anything, do you hope to gain from working with the career coach?


13) How did you hear about our coaching services?


14) Additional comments:

As a security measure, please fill out the Captcha below. Enter the letters and numbers exactly as you see them listed then click the "send" button.