Name
Email
Phone Number
Have you ever worked with a leadership coach before? Select an option
Yes
No
How long have you been in a leadership position?
What is your current job title?
What department or type of unit do you currently manage? Select an option
Medical-Surgical
Telemetry/Step-down
Intensive Care Unit (ICU)
Emergency Department (ED)
Perioperative Services (OR/PACU/Surgical Services)
Labor & Delivery
Postpartum/Mother-Baby
Neonatal Intensive Care Unit (NICU)
Pediatrics
Behavioral Health/Psychiatric
Oncology
Rehabilitation
Long-Term Care/Geriatrics
Float Pool/Supplemental Staffing
Ambulatory/Outpatient Services
Case Management/Utilization Review
Administrative/Non-Clinical
Other
Multiple areas
If "other," please describe:
What aspect of leadership are you hoping to improve or get support with? Select an option
People and team management (e.g. critical conversations, accountability, generational differences, conflict)
Resource shortages (e.g. staffing, supplies, equipment, materials)
Time and organization (e.g. too many meetings, daily tasks, competing priorities, delegating effectively, creating systems)
Communication and collaboration (e.g. communicating effectively, navigating multidisciplinary collaboration)
Culture and engagement (e.g. low morale or burnout, retention, staff engagement or satisfaction)
Clinical quality and regulatory responsibilities (e.g. staying compliant with policies, managing incidents or audits, ensuring safety metrics)
Technology (e.g. utilization of various technologies)
Personal well-being and leadership identify (e.g. emotional exhaustion, work-life balance, imposter syndrome or confidence, role clarity, navigating stress)
Career advancement
Other
Multiple aspects
If "other," please describe:
What takes up most of your time in a typical day or week? Select an option
Staffing and scheduling
Administrative tasks
People and team support
Clinical and operational oversight
Projects and strategic work
Personal leadership and organization
Constant interruptions/reactive days
Other
If "other," please describe:
On a scale of 1-10, how would you rate your current work-life balance? (1= Extremely unbalanced, 10= Excellent balance) Select an option
1–2: Constantly overwhelmed, no time for yourself outside of work
3–4: Struggling to maintain boundaries; work often spills into personal time
5–6: Some balance, but inconsistent; work regularly affects home life
7–8: Generally balanced with occasional stress or spillover
9–10: Strong boundaries, consistent self-care, feel in control of work and personal life
What are you looking for in a coach?
How do you prefer to be supported in your journey? Select an option
One-on-one personalized guidance
Structured framework with accountability
Collaborative learning
On-demand tools and resources
Real-time support
Reflective and emotional support
Other
Multiple
If "other," please describe:
What is your preferred level of communication and access? Select an option
Frequent check-ins and direct messaging
Bi-weekly check-ins
Monthly check-ins
Quarterly check-ins
Less frequent, only when needed
What would make this experience a success for you?
Please let me know which of the following might make it challenging to fully participate in leadership coaching. Select an option
Lack of support
Lack of resources
Lack of time
Lack of funding
Lack of confidence
Other
None
If "other," please describe:
To better understand how your role has been affecting you, please select any impacts you’ve experienced (if you’re comfortable sharing). Select an option
Took time off or required extended leave
Began or increased use of medication(s) (e.g., for blood pressure, anxiety)
Persistent physical exhaustion
Emotional overwhelm, stress, or anxiety
Noticeable decline in focus, productivity, or performance
Difficulty coping with day-to-day stress
Difficulty being present with family or loved ones
Concern about your overall well-being
Blood sugar/not eating
Weight changes
Loss of enthusiasm/connection/hope/questioning staying in nursing management
Other
None
Prefer not to share
If "other," please describe:
When it comes to making your personal and professional goals a priority, what level of investment feels aligned for you? Select an option
$500- $2,000
$2,000-$5,000
$5,000k-$8,000
$8,000-$10,000
$10,000+
How committed are you to reaching your goals? Select an option
Fully committed, willing to do whatever it takes
Somewhat committed, but need support
Looking for guidance, but not sure if I can fully commit yet
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