1. Form A: Coaching Application
Name:
E-mail address:
Phone number:
Position/title:
Name of Center: POC Name:
POC Phone number:
Type of Request: Length of Service:
Initial: Extension: Senior Executive Service: YES NO
If No:
Number of Hours Requested: GS Level:
Coaching Hours Used to Date: Potential Coaches have the option to contact
Coachee after one week for follow-up:
Total Number of Hours Expected:
YES NO
Preferred characteristics of coach (i.e. gender, background, style, special expertise) or specific
preferred coach in the local geographic area:
Professional goals:
Goals and reason for desiring coaching:
List any relevant assessments you have recently had that could be provided to the coach:
Have you ever had a coach before? If so, what was your experience?
How soon would you like to get started with a coach?
Other considerations (e.g., type of coaching, availability, etc.):
Supervisor’s Name: Supervisor’s Email:
Supervisor’s signature: Date: