One-to-one Career Coaching and Benefits Planning Services Request

Can you utilize various technologies with minimal guidance to engage in online coaching and counseling services?* This field is required.We serve all of Colorado remotely, with most services conducted online. In-field observation, benefits reviews, and data collection are available only in Greeley and surrounding Northern Colorado areas on a case-by-case basis. Regardless, participants working with us must engage with technology in various capacities to attend routine coaching and counseling appointments effectively. We provide resource guides and offer a comprehensive self-directed onboarding course with guides and resources to introduce participants to our systems.

YESNO

Technology Policy

Regular meetings will occur online using various technologies.

Individuals seeking services with us must have the necessary technology skills to navigate the online coaching and counseling setting to ensure that technology won't be a barrier to their experience.

Based on this information, do you feel that your response to the previous question remains accurate?

If "yes," click "Next." If "no," click the back button and change your answer.

Have questions before you decide? View our technology support site

Please select the option that best describes you* This field is required.

I am the prospective client.

I am someone else other than a third-party referring agency representative.

I am a third-party referring agency representative.

What methods of payment do you anticipate utilizing?* This field is required.Check all that apply.

Insurance

Third-party Payment or Authorization - Do not check this unless you have an open and active case with the referrer AND can provide contact information for your case manager or counselor.

Cash

Other

Full Name* This field is required.Please provide us with your (the client's) full name.

First Name

Last Name

Preferred First Name* This field is required.What is the prospective client's preferred name?

Email* This field is required.Please provide your(the client's) email so that we can create an account for documentation and coordination of appointments. If third parties need access to client data, a signed release is required before granting them access to client data. Do not provide an email that a prospective client cannot access directly.

example@example.com

Phone Number* This field is required.Please note that we will use the phone number to coordinate services if the referral is accepted and we move onto the meet and greet stage or directly into coordinating services. Please review the terms noted in the next question to confirm permissions to text you regarding the coordination of your services.

Please enter a valid phone number.

By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message and agreeing to our Privacy Policy. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information.* This field is required.Click "Yes" if you agree to these terms.

YESNO

Our caseloads are always changing. However, if turns out there’s a potential client-provider fit but no open slot, would you like to be placed on the waitlist with that provider?We note that waitlist times are constantly changing and we cannot predict when a provider will become available. However, you do not need to keep track of us. We review lists often, and we will reach out to you when space becomes available.

YESNO

What is your goal? Please share what you can in the space provided below.Please list the Job Goal, whether it is full-time or part-time, and if they are looking for remote, hybrid, or no preference, what their barriers are, and/or support needs so I can evaluate the referral effectively. Please note that if you are planning to attach an IPE at the end of this form, you can skip the details and just list the Job Goal, whether it is PT/FT or remote/hybrid target position.

Please select what best describes where you (the client) are at in your career. Checking all that apply.strategy I am going to recommend.

Career Starter i.e., New to working has less than 1- 3 years of full time work experience in a specific position or field.

Career Promoter i.e., seeking a position that is higher than the one they are in.

Career Changer i.e., has at least some work history, but no work history in their target job goal or industry.

Career Maintainer i.e. seeking a role that they have at least 3-5 years of established work history in.

Career Transitioner i.e., they are looking to change position within an existing field.

Interagency Referral Representative's NameIf you are the interagency rep, or the individual requesting services and plan to work with a third party agency to get assistance with covering cost of services list your contact person's name here.

First Name

Last Name

Interagency Referral Representative's EmailIf you are the interagency rep, or the individual requesting services and plan to work with a third party agency to get assistance with covering cost of services list your contact person's email here.

example@example.com

What kinds of services would you (the client) like to set up?* This field is required.Please check all that apply.

Career or Job Coaching i.,e., targeting a high fit position, resume and cover letter development, job search strategy, interviewing, interview preparation, salary negotiation, accommodations, Interpersonal communication related to job search and work etc.

Career Exploration or Plan Development Support i.e., structured coaching to determine a job goal or high fit career pathway or Assessments to inform employment plan.

Interpersonal Systems and Process Coaching in work or life to help establish positive job goal outcomes and address barriers to access employment sustainably.

Benefits Counseling or Work Incentives Planning to understand impact of returning to work while on federal or public benefits.

Information and Community Referral Services i.e., help filling out public or federal benefits applications,

Professional Counseling i.e., social, and emotional clinical coaching to help improve quality of WorkLife Journey, seeking to positively affect work experiences on the job etc. [Please note that we are taking insurances for this service. ]

Work Adjustment Training to coach navigation with in new systems, set up processes and systems in a new job, or Personal Adjustment Training to coach navigating daily living activity adjustment in order to return to work, and retain work.

Other

How would you like us to proceed with contacting the prospective client regarding the services request?

I would like to schedule a Group Meet and Greet online with all parties.

I would like WorkLife Wellness Lab to schedule a Meet and Greet by PHONE with the client directly and report back to me regarding the outcome.

I would like WorkLife Wellness Lab to go ahead and set up services because the case has already been discussed and agreed upon between parties.

Please attach a copy your most recent resume and cover letter.If you have a copy of the IPE, and/or already an auth in place, you can attach those here too.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Thank you for requesting one-on-one Career Coaching and Benefits Planning Services. The information provided will help us coordinate services with you.

We review all submissions with client-provider fit as a key factor in accepting requests for services. Caseload availability changes frequently so we reveiw all requests for services as they are receieved.

Waitlist Requests

If there is no open slot and you’ve agreed to be added to the waitlist, we’ll notify you email that your request was received and you have been placed on the waitlist.

Waitlists for providers are reviewed often, and the provider you have been waitlisted with, will reach out to you directly once a slot with with them becomes available.

One-to-one Career Coaching and Benefits Planning Services Request