APPLICATION FOR ADMISSION
Coach Success Network
Application
Name:
Address:
City: State: Zip:
Country:
Phone Numbers - Home: ____________ Mobile: __
Work: Circle your preferred contact number: Home Mobile Work
|Personal E-mail address: |
|Business E-mail address: |
|Date of Birth: |
|Name of Business: |
|Business License ID #: |Expiration: |
What Institute or Debbie Ford Trainings or Courses have you completed?
ο Shadow Process Workshop Location _____________ Date _______
Location _____________ Date _______
ο Shadow Process Assistant Location _____________ Date _______
Location _____________ Date _______
ο Essentials One / Breakthrough Date _______
ο Essentials Coaching Training Date _______
ο Blueprint Coaching Training Date _______
ο Spiritual Divorce Coaching Training Date _______
ο Evolution into Mastery Date _______
ο One-Day Workshop(s) Title(s) ____________________ Date(s) _________
Title(s) ____________________ Date(s) _________
ο Teleclass(es) Title(s) ____________________ Date(s) _________
ο Lecture(s) Title(s) _________________ Date(s) _________
ο Other _____________________________________________________________
ο Cruises ____________________________________________________________
|Certificates and Dates Received from The Institute of Integrative Coaching? |
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|Are you certified to one day’s or tele-classes through The Institute of Integrative Coaching? |
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|ACADEMIC CREDENTIALS: |Years completed |School |Graduated/Degree |
|HIGH SCHOOL: | | | |
|COLLEGE/UNIVERSITY: | | | |
|BUSINESS/TECHNICAL: | | | |
|OTHER: | | | |
|GRADUATE OR DEGREE: | | | |
|FIELD OF STUDY: | | | |
|ADDITIONAL CREDENTIAL; PHD, MA,MBA, | | | |
|ADV.Certifications | | | |
|(Please list) | | | |
|Are you an active ICF member? Or ICF Credential? Other Governing Organization? |
| |
|Do you currently have a full time or part time coaching business? |How many Clients? 1-3, 3-6, 6-9, 10 or more |
| | |
|Do you currently have another occupation? Y or N |Do you work part time or full time? |
| | |
|What is your current hourly fee? Under 75, 75-100, 100-200, 200 and above? |
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|How would you rate yourself as a coach? In terms of experience, skills, listening, greatest strength, areas to improve, responsibility, paper work, |
|organization and tracking. Please respond in a brief paragraph. |
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Below is a chart of days and times during the week, please indicate your availability for coaching appointments.
| |SUN |MON |TUES |WED |THUR |FRI |SAT |
|4A – 6A | | | | | | | |
|6A - 8A | | | | | | | |
|8A - 10A | | | | | | | |
|10A-12P | | | | | | | |
|12P- 2P | | | | | | | |
|2P- 4P | | | | | | | |
|4P – 6P | | | | | | | |
|6P – 8P | | | | | | | |
|When can you begin to work with Clients? What date? | |
|Would you be willing to offer sample sessions at no fee to determine if you |Would you be willing to have a sample session at $60.00 and split it 50/50 |
|are a match with a potential client? Yes or No? |with CSN? Yes or No? |
| | |
References:
Personal Reference (not family)
Name ____________________________________________
Email __________________________________________________
Phone __________________________________________________
Known for how long?_________________________________________
Integrative Community Reference:
(Please list a mentor, staff, reviewer, person who has experienced you as a coach)
Name __________________________________________________
Email ___________________________________________________
Phone ___________________________________________________
How do you know this person?_________________________________
The following questions are to help determine a match with potential clients
On a scale of 1-5 please rate yourself as a coach in the areas of the life wheel: (5 being strong, personal experience and passion to coach in, and 1 being not interested or connected to area)
|HEALTH/WELL-BEING | |
|MONEY AND FINANCES | |
|PRIMARY RELATIONSHIPS | |
|FAMILY AND FRIENDS | |
|SPIRITUAL DEVELOPMENT | |
|FUN AND LEISURE | |
|WORK AND CAREER | |
|HOME AND SURROUNDINGS | |
|What do you believe are your three strongest individual qualities? Please pick the top three |
|1.Wisdom 11.Self Discipline |
|2. Kind 12. Power |
|3. Creative 13. Energetic |
|4.Honest 14. Health |
|5. Motivated 15. Entrepreneurial Spirit |
|6. Tenacity 16. Clarity |
|7.Confidence 17. Organized |
|8. Independence 18. Spiritual |
|9. Trust 19. See Large Picture |
|10 Committed 20. Financial Intelligence |
|Do you have a gender preference? M, F, no preference | |
Is there a particular age group that you want to coach and don’t want to coach? Y or N
|Teens | |
|Between 20-60 | |
|60 and above | |
|other | |
Language you can coach in? Y or N (list other)
|English | |
|Dutch | |
|Spanish | |
|French | |
|German | |
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Specialty Areas
Please check the areas that you are drawn to and passionate about; please be as specific as possible
Relationship
( Parents ( Children ( Couples ( Gay Life Style ( Friendships ( Work
Career
□ Finding New Career ( Dissatisfaction with current career ( Business Owner ( Executives
Health and Wellness
( Weight Issues ( Aging ( Sports
Life Transitions
( Marriage ( New Parent ( Adoption ( Empty Nest ( Divorce ( Remarriage
( Retirement ( Caring for elderly parent ( Moving
DECLARATION
I HEREBY DECLARE THE INFORMATION PROVIDED IN THIS DOCUMENT IS COMPLETE AND ACCURATE. I UNDERSTAND THAT A FALSE STATEMENT MAY DISQUALIFY ME FROM FURTHER CONSIDERATION FOR COACHING REFERRAL.
I HAVE READ AND UNDERSTOOD THE INFORMATION PRESENTED IN THIS DOCUMENT.
PRINT NAME _____________________________
SIGNATURE ______________________________ DATE ________________________
Thank you for taking the time to provide us with this information.
Please scan and e-mail it to stepup@
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