Comcast Cohort 5: Intake Form

Coaching Intake Form

CoachDiversity Institute looks forward to providing you with one-on-one coaching support. We recommend that these sessions take place on a biweekly basis, as your schedule permits.

CONFIDENTIALITY: The only individuals who will have access to this intake form responses are designated individuals at CoachDiversity Institute and your coach. The information will be used for goal-setting purposes and to measure the impact of the program. Information will remain confidential at all times.
Name*

First NameLast Name
Pronouns*

she/herhe/himze/hirthey/them
Business Unit*
Title*
Your Work, Your Goals
Briefly describe your professional role.*
Provide any applicable web-links describing you and your work. *
Which of these topics would you like to cover with your coach?*

Active listeningAllyship in actionBuilding inclusive leadership skill sets among your teamBuilding your brand as an inclusive leaderCreating, maintaining and contributing to psychologically safe spacesHandling microaggressionsLeading and managing diverse teamsLeading through uncertainty/during times of changeProviding timely, actionable, and achievable feedbackReceiving and actioning feedbackDeveloping and navigating mentorship/sponsorship relationships
What results would you like to gain from this coaching experience?*
What is one major goal you'd like to achieve in the next six months that impacts your effectiveness in the workplace? *
What is in your way of accomplishing this goal?*
What are you currently doing to build or elevate inclusivity as a leader? Additionally, what are you struggling with?*
What would you like your coach to know in order to be the best possible coach for you? What tips could you give them to coach you most effectively?*
Self-Assessment

How fulfilled are you with the choices you've made in the last 6 months?*

	1	2	3	4	5

1 is Not fulfilled at all, 5 is Extremely fulfilled

How much stress is in your life right now? (personal or professional)*

	1	2	3	4	5

1 is No Stress, 5 is High Stress

What has been causing your stress lately?*

0/1000
Your Leadership

Please rate your own leadership competencies in the following areas.

Vision*

	1	2	3	4	5