Client Intake Form

1

Let's Start with the Basics

Tell us who you are so we can set everything up.

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First Name *

Please enter your first name

Last Name *

Please enter your last name

Middle Name

Preferred Name

Email Address *

Please enter a valid email (e.g. name@example.com)

Phone Number *

Please enter a valid 10-digit phone number

2

Where Are You Located?

This helps us coordinate scheduling across time zones.

Country *

Please select your country

State *

Please select your state

City *

Please enter your city

Zip Code *

Please enter a valid 5-digit zip code

Province *

Please select your province

Postal Code *

Please enter your postal code

3

Your Military Service

Tell us about your connection to the military.

Current Military Status *

Please select your military status

Veterans or Active duty, what branch did you serve? *

Please select the branch you served in

Spouse or Caregiver, what branch are you affiliated with? *

Please select the branch you are affiliated with

Service Start Date *

If family, use your loved one's date.

Please enter a valid date (MM/DD/YYYY)

Service End Date *

If family, use your loved one's date.

Please enter a valid date (MM/DD/YYYY)

Have you participated in a previous VCP coaching cohort? *

Yes

No

Please select an option

4

Your Coaching Goals

Help us understand what you'd like to achieve.

What types of coaching are you interested in? *

Select all that apply.

Career CoachingIdentify career goals, develop skills, and create strategies to achieve professional success

Business CoachingImprove skills, strategies, and overall performance in business endeavors

Life CoachingClarify goals, overcome obstacles, and achieve personal and professional growth

Health & Wellness CoachingAchieve holistic well-being by addressing physical, mental, and emotional health

Leadership CoachingStrengthen strategic thinking and decision-making

Transition CoachingMilitary-to-civilian transition, job loss or career displacement, or returning to work after an extended absence

Neuro-Diversity CoachingWorking with folks who process information differently and uniquely

Please select at least one coaching type

What accomplishments are you looking to achieve? *

Please describe your goals

What gets you excited about life? *

Please share what excites you

Can you commit to 12-15 one-hour virtual sessions with your coach? *

Yes, I can commit

No, not at this time

Please select an option

Are you able to be fully present with your coach for this 15 week program? *

Yes

No

Please select an option

5

Tell Us More About You

A few final details so your coach can get to know you.

How did you learn about VCP? *

Please tell us how you found VCP

Who referred you to VCP? *

Please tell us who referred you

What obstacles or challenges do you anticipate you might face during this program, if any? *

Please share any anticipated challenges

6

Almost There!

Write a short bio and upload a headshot for your coach.

Brief Bio *

This will be shared with your coach to help them get to know you.

Please write a brief bio

Headshot *

Click to upload your headshot

JPG, PNG, max 5MB

Please upload a headshot

May we contact you in the future about VCP updates? *

Yes

No

Please select an option

Let's Start with the Basics

Where Are You Located?

Your Military Service

Your Coaching Goals

Tell Us More About You

Almost There!

Application Submitted!