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? |

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|Do you currently have a full time or part time coaching business? |How many Clients? 1-3, 3-6, 6-9, 10 or more |

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|Do you currently have another occupation? Y or N |Do you work part time or full time? |

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|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? |

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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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