Career Coach Intake Form



Note: Please bring a copy of your most recent resume to your appointment!

Demographic Information:

Name:                                                                     Date:


Home/Mobile Phone:                                                Is it ok to leave a message for you at this number? Y / N

Work Phone:                                                            Is it ok to leave a message for you at this number? Y / N

Email:                                                                      Is it ok to email you? Y / N

Mailing Address:

Current occupational status: (i.e., F/T, P/T, self-employed, student, returning to work):



How were you referred?                                            If online, which website?


  1. Briefly list the highest level of formal education you have obtained and any other relevant education, certifications, or specialized training:



  1. What subjects have you most enjoyed studying?



  1. What subjects have you least enjoyed studying?


Employment Information:

  1. Current job title/employer:



  1. Years in current position:



  1. Are you having any difficulties/stressors in your current job? If so, please briefly describe those difficulties.



Career Information (please use as much room as needed):

  1. Why are you seeking career counseling?



  1. What do you hope to accomplish from career counseling?



  1. On a scale of 1 to 10, with 1 being "Least Satisfied" and 10 being "Most Satisfied," how satisfied are you with your current career?



  1. What would you most like to change about your current career?



  1. What are your current career goals? (Even if you are very uncertain, just fill in any thoughts that you might have.)



  1. If you could do anything you wanted, what would it be?



  1. Which 3-5 of these values is most important to you regarding your work?
  • __________  Achievement
  • __________  Creativity
  • __________  Helping Others
  • __________  Helping Society
  • __________  Environment
  • __________  Money
  • __________  Status/Recognition
  • __________  Free Time/Leisure
  • __________  Leadership
  • __________  Moral Fulfillment
  • __________  Intellectual Stimulation
  • __________  Self-Direction
  • __________  Stability
  • __________  Security
  • __________  Variety
  • __________  Authority
  • __________  Enjoyment
  • __________  Competition
  • __________  Challenge/Adventure
  • __________  Independence


  1. What kinds of barriers could get in the way of meeting your career goals?



  1. List aspects of all your prior experience that you MOST liked:



  1. List aspects of all your prior experience that you LEAST liked.



  1. What are the skill requirements for your next job (the job you are seeking or would like to pursue)?



  1. What are the top three skills that you offer an employer?



  1. What can you do easily that other people find difficult?



  1. What is difficult for you that others seem to find easier?



  1.   How do you like to spend your leisure time?




   1.    Have you invested in Career Coaching service before?


   2.    Were the results helpful?