Questionnaire: Please complete and return to your coach along with a resume & references.
This information helps your coach to effectively work with you.

Name

Date

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone, with Extension

Best time to contact you

US Citizen:    Ο Yes   Ο  No … If No, Do you have a Visa:   Ο Yes  Ο  No    Type of Visa:

Education:      Ο High School    Ο College   Ο Graduate School      Ο Pharmacy    Ο Medical School

Degrees

Special Skills & Certifications

Job Type Preference

Current Salary

Aspired Salary

Aspiring Jobs Titles

Where in the World would you want to live and work?

What are your activities outside of work?

Employment Information

Current Employer

Type of Company

Job Start Date

Years Employed

Experience

Previous Employer

Type of Company

Start Date

End Date

Years Employed

Experience

Previous Employer

Type of Company

Start Date

End Date

Years Employed

Experience

Please provide three references from  your past employers or a list of professional references.

And now for our twenty questions

1.    What do you especially like about your current position?

2.    What made you decide to become a healthcare executive (fill in another field list your occupation)?

3.    Have you ever regretted it?

4.    Do you have any specialized training?                                   If so, describe.

5.    What do you do especially well on the job?

6.    What do you consider to be your strengths on the job?

7.    Your weaknesses?

8.   Do you think that your current employer appreciates your work?

9.   Do you think you are fairly compensated by your current employer?

10.   Would you leave if you were offered more money somewhere else?

11.   What could your current company change to make your work easier?

12.   What do you think your company would say if you give your notice?

13.   Do you work in a middle or upper level management capacity?    o middle   o upper 

a.       How long have you been in management?

b.       Do you have hiring and firing authority over you subordinates? Have you hired or fired anyone while in this position?

c.        Do you have training responsibilities? Have you recommended coaching to any of your colleagues or subordinates?

d.       Are you responsible for a budget? How big?

14.   Have you spoken an executive coach before today? Did you engage their services? Why or why not?

15.   What personal development programs or activities have you engaged yourself?

16.   Do you believe that coaching will benefit you?

Complete the followings questions if you are a licensed medical practitioner

17.   In which states are you licensed?

18.   Has your license to practice ever been suspended?  Ο Yes  Ο No  If yes, for what reason?

19.   Have you ever been convicted of a felony?  Ο Yes  Ο No    If yes, for what reason?

20.   Have you ever had to settle a medical malpractice suit? Ο Yes  Ο No  If yes, under what circumstances?