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Individual Intake Form
Full Name
Preferred Name? Nickame
Phone Number
Your Email
*
Job Title & Company
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Industry or Field
Address
*
Brief Professional Bio & Experience
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Years of Experience
Previous Roles/Key Career Milestones
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Notable Achievements & Recognitions
Key Skills & Areas of Expertise
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Certifications & Professional Affiliations
Core strengths as a leader & how you leverage them?
Preferred learning style
Reading
Listening
Discussing
Doing
Preferred working style
Alone
Team
Leading a Team
How you measure success and effectiveness ?
Core values guiding business & leadership decisions
Most important contribution in your business right now
Current challenge you'd like insight or support on
How you build trust and relationships with your team/stakeholders
Current projects that others might be able to support
Where you see yourself & your business in 5 years
*
Hobbies & Personal Interests
Philanthropic or Volunteer Work
Philanthropic or Volunteer Work
One thing most people don’t know about you
Connections you are looking to make within the group
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