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Name of Business / Organization
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First Name
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Last Name
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Job Title (i.e. Owner, CEO, Etc)
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Number of Employees
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1 to 9 Employees (Small Business)
10 to 49 Employees (Small Business)
50 to 249 Employees (Small to Medium Enterprise)
250 or more Employees (Large Enterprise)
Street Address
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Address Line 2
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
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Phone Number
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Email Address
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1. What would be important for me to know about you and your role within your company?
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2. What should I know about your personal and professional background or history that you believe will help me understand you and allow me to better support you?
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3. What have been your three most fulfilling accomplishments in your career so far; whether at this company or another?
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4. What goals do you want us to focus on (for you and or your company) in the next 3-6 months for?
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5. What key issue do you want to address first?
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6. What, if anything, is likely to get in the way or prevent us from accomplishing any of these things?
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7. How can I be helpful to you and or your company as a coach?
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8. As it relates to your company what history, issues or concerns should I know about that you believe will help me better understand the context of providing leadership coaching to your company?
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9. What's the most important thing(s) you need from me as we work together?
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10. What questions do you have of me?
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