Strategy Session Registration Form

Application: Uprising Program
Thanks for your interest in my 12-week Uprising Program. Please answer the questions below. If we haven't worked together or spoken previously, I'll be in touch to schedule a complimentary 30-minute Career Clarity Session to see how we vibe and better understand your goals.

This private coaching experience includes: 9 video modules with worksheets, 2 45-minute coaching sessions, a Top 5 Clifton Strengths assessment and weekly email check-ins.

The investment is $1297 (or 3 installments of $499).
Name*

First NameLast Name
E-mail*
Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How committed are you to make a change at work?*

	1	2	3	4	5	6	7	8	9	10

1 is Not at all, 10 is Fully Committed

What are your 3 most important career goals for the year ahead?*
How would your life change if you could achieve the goals listed above?*
What holds you back from making progress, if anything?*
Why do you want to work with me for private coaching?*
Which statement(s) best describes your current situation? (Choose up to 3)*

I am bored in my current role.I am burned out in my current role.I feel trapped by my degree and/or training.I want to re-energize my existing position.I am ready to reinvent myself for my next career.I want to apply my expertise in a new organization.I need to make a change but I don't know where to start.I made a change and want more momentum.Other
I understand that the investment for private coaching starts at $1297 (this is an acknowledgment, not a commitment).*

YesNo
Would you like to join the 'Engineer Your Bliss' community and receive periodic updates via email?

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Application: Uprising Program