Coaching with Laurence Boldt

Coaching Services Application

Name:

Current Occupation (if any):

Home Address:


Mailing Address (if different):


Email Address:


Birthdate:

Marital Status: Single Married

Do you have children? Yes No

If yes, what age(s)?:

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 career assistance? What, more
than anything, do you hope to gain from working with a career coach?


13) Which program are you applying for?


14) How did you hear about our coaching services?


15) Additional comments: