Name:

Occupation:

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) and degrees if applicable.


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

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


How did you go about selecting the career you are currently in? Briefly describe.


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


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


What are your main interests outside of your current work?


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

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.)


If no, do you have an idea of the field you would like to move into? Yes No

If yes, describe:


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


What are your primary goals in seeking career assistance? What, more
than anything, do you hope to gain from working with a career coach?


Which program are you applying for?


How did you hear about our programs?


Additional comments: