Life Coach Assessment Form

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Q1 - Full Name* This field is required.What should I call you?

First Name

Last Name

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Q2 - Email Address* This field is required.Provide the best email to reach you for schedule changes or administrative requests.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

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Q3 - Phone Number

Please enter a valid phone number.

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Q4 - Organization / Event NameWho are you representing today? If this is for a specific event, drop the event name here.

Ex, Company, Organization, Event, Individuals Name

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Q5 — Engagement Type* This field is required.What kind of moment are we creating?

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Q6 — Timeframe* This field is required.When are you looking to make this happen?

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END OF MODULE 1Thanks for reaching out

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Great — you're exactly the kind of leader I love working with. A few more questions so I can bring my A-game to our conversation.

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Q8 — Audience TypeWho am I speaking to?

Senior leaders / executives

Mid-level managers

Sales teams

Veterans or military community

Entrepreneurs / founders

Frontline employees / associates

Students or emerging professionals

Mixed audience

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Q9 — Budget RangeWhat's the investment range you've set aside for this engagement? Straight talk saves us both time. Ranges are fine — I'll meet you where you are when it's the right fit.

Under $5,000

$5,000 – $10,000

$10,000 – $20,000

$20,000 – $35,000

$35,000+

Not sure yet — open to guidance

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Q10 — Desired Outcome (Short Text)When your audience walks out of that room, what do you want them feeling, believing, or ready to do?

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Great — you're exactly the kind of leader I love working with. A few more questions so I can bring my A-game to our conversation.

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Q11 — Event / Business ContextSet the stage for me — what's the event, who's the audience really, and what's the bigger story you're telling with this program?

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Q12 — The TransformationWhat's the shift you need in this room? What are people currently believing, doing, or tolerating that has to change?

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Q13 — Constraints & LogisticsWhat do I need to know about the format, tech, travel, or dates?

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Q14 — Success DefinitionFast-forward 90 days after the engagement — what's different? How will you know I delivered?

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Q15 — Upload Supporting Materials (Optional)Got a brief, agenda, deck, or run-of-show? Drop it here.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

Totally optional — but if it exists, share it. Every detail helps me tailor.

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Q16 — How You Found Me (Optional)Last thing — how did we cross paths?

The Momentum Shift podcast

Referral from a colleague

Speaker bureau or directory

Saw me speak somewhere

Google or web search

Other

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THANK YOU

That's it. You just did the hard part.

Here's what happens next:

I personally review every response within one business day.
If we're aligned, you'll get a calendar link to book a 30-minute strategy call — no pitch, just clarity.

From there, we build the moment your audience will still be talking about six months later.

Until then, remember: momentum is a decision. You just made one.
— C. Eric Collier

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EXPLORE ADDITIONAL OPTIONS TO ADD VALUE FOR YOUR EVENT ATTENDEES