Coaching Application | The Confident Living & Leadership Alliance
Apply to work with Dr. Whitaker-Riley and begin your transformation. Please complete all sections thoughtfully and have your details ready.
Personal Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City & State
*
Preferred Contact Method
*
Email
Phone
Text
Vision & Goals
Why are you seeking coaching?
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What areas do you need support with?
Personal growth
Confidence & identity
Leadership development
Business/career direction
Life transitions
Emotional healing
Other
What would success look like for you in the next 6–12 months?
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Readiness & Commitment
How committed are you to making meaningful change?
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Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
What have you tried so far?
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What is currently holding you back?
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Support Needs Assessment
Are you currently dealing with unresolved trauma, clinical mental health concerns, or emotional distress that may require therapeutic support?
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Yes
No
Unsure
Are you currently in therapy or have you been recently?
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Yes
No
Which best describes what you need right now?
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Clarity and direction
Emotional healing and support
Both
Faith & Alignment
How important is faith in your coaching process?
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Very important
Somewhat important
Not a primary focus
Are you open to faith-based coaching with biblical principles?
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Yes
No
Coaching Investment
Investment & Next Steps
Are you ready to invest in coaching at this time?
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Yes, I am ready to start
I want details first
Not at this time
Preferred coaching type
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1:1 private coaching
Group coaching - The Alliance
Not sure yet
Final Alignment
Why do you believe this is the right next step for you?
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What does success look like for you in this coaching journey?
*
Anything else you would like to share
Submit
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