Registration: 1-1 Life Coaching
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Have you attended a Success Accelerator workshop/program in the past?
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Referred by (please include the organization and name of the person)
Which of the following do you identify with?
Involved with the Justice System (means a history with the criminal justice system and/or agencies such as John Howard or Elizabeth Fry)
Experienced mental illness (either self-identify or clinically diagnosed)
Gender-Based, Intimate Partner and Family Violence
In or are leaving the care of the Children's Aid society
Low Income/ on Social Assistance (Low income means an individual who ears less than $20,778 per year or $41,198 per year for a family of four, Social Assistance includes government income subsidy including EI, OW, ODSP, or Basic Needs Allowance)
Newcomer (means individuals who have resided in Canada for less than five years)
Person with a Disability (this includes any physical disability, mental impairment, developmental disability or learning disability)
Racialized (means groups of people who might experience unequal or different treatment on the basis of race, ethnicity, language, religion or culture)
Single parent (self)
None of the above
What is your highest level of education?
Some High School
What interested you about this coaching opportunity?
What is it that you really, really want to create in your life, and why?
What is holding you back from getting there? (Fears, habits, insecurities, time, people, etc.)
How will your life feel and what will it look like when you get there?
List your 1-3 most important goals for coaching that will support moving towards your desired future
Specifically, which personal qualities, habits, and behaviors do you want to develop to help you reach these goals?
What are you willing to commit to in order for you to realize your goal?
Is there anything else you'd like me to know about you?
What questions or concerns do you have?
By continuing with this application, you agree to the following terms and conditions:
If you indicated that you are referred by an organization or someone, we may share the attendance of your participation in our program(s) with the organization or person as indicated https://www.successaccelerator.ca/terms-and-conditions AND https://www.successaccelerator.ca/media-release
Yes, I have read and agree to the statement set out above and the Terms & Conditions.
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