Leadership Mirror Survey

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Current Role / Title* This field is required.

4

Organization Name(Optional)

5

Do you currently lead a team or have regular collaboration with others at work?* This field is required.

Yes

No

Not currently, but I have in the past

6

How many people do you work with regularly who could give you honest feedback?* This field is required.(direct reports, peers, or supervisors)

Fewer than 5

5–10

11–15

More than 15

7

Are you currently navigating a change or challenge in your leadership?* This field is required. (promotion, team shift, new goals, feedback concerns, etc.)

8

What is motivating you to pursue a 360 assessment at this time?* This field is required.(E.g., leadership growth, tough feedback, transition, team feedback, etc.)

9

Have you ever completed a 360 assessment before?* This field is required.

Yes

No

Not sure

10

Are you looking for:* This field is required.

A one-time diagnostic snapshot

A deep-dive and coaching support

Not sure yet

11

If invited, are you open to investing in a high-trust leadership assessment with strategic support?* This field is required.(Starts at $2,995 with flexible payment)

Yes, I’m ready

I’m interested but have questions

No, I’m not in a position to invest right now