* Name:

* Mailing address:

* City:

* State:

* Zip:

* Time Zone:

* Home phone:

* E-mail address:

* Age:

* Employment:
What is your current or most recent job title?
Dates of employment in this position?
How did you get involved in this occupation?

* Education: What is the highest educational level completed? (If you have college degree(s), list each with its emphasis--for example: B.S., Nursing)

* What career issues are you currently experiencing?
My work is not a good fit for who I am
My work is not satisfying or meaningful
My work environment affects me negatively
My boss and/or co-workers affect me negatively
I want to do something different with my career, but don’t know what that would be
I feel like God is calling me to do something else, but I don’t know what it is
I know what I want to do but don’t know how to make it happen. (Please explain in the box below.)
(Students) I need to choose a college major/degree program/career direction
I need to find a career in which I can earn more money
I want to improve my job search tools (resume, LinkedIn, etc.) and strategies (finding jobs, interviewing, etc.)
Other (Please explain below.)

* Please explain your most significant career issues:

* Have you ever worked with a professional career coach/counselor before? If yes, who? What did you do with that person? What were the results?

* Why are you seeking professional career coaching/counseling at this time? What are you looking for from a career coach/counselor?

* If you were in the ideal career/job, what would that do for you?

* What do you think could be slowing you down, standing in the way, or stopping you from finding work that is a good fit for your God-given design?
Low Self-Confidence
Lack of Clarity in Values
Lack of Time (i.e., Inability to Prioritize)
Fear of Change
Fear of Failure
Lack of Motivation
Other People
Depression
Fear of Others' Disapproval
Other (please describe below)

* Please explain the most significant issues you experience:

* If you could turn all these challenges around and find work that you were designed to do what would that do for you?

* Career Services: Which of these services do you think could meet your needs? (You can find a description of each by clicking on the link.)
Live Your Calling Career Program
Professional Career Testing Package
Professional Career Testing for High School/College Students
Job Search Mastery Program
Monthly career coaching
Resume writing services

* Services and packages range from $149 to $1595. We also offer monthly payment plans for programs which can be as low as $136 per month.

Please Note: For most people services are tax deductible under career development and/or job search activities. (Check with the IRS or your tax advisor for appropriate categories.)

Finances: Which best describes your situation?
I can afford to pay for whatever services would best fit my needs.
I would need some assistance to afford career services.
I could afford monthly career coaching at the rate of $250
I could afford minimum monthly payments of $130 for career programs that would meet my needs.
Other (Please explain below)

Comments about your financial situation:

* Scheduling Your Session: Please provide several dates and blocks of time (Monday through Friday from 2pm to 8pm Eastern time) during which you would be available for us to call you for your complimentary consultation session. Also, please note which phone number to use for each time listed.