Welcome to Your Career & Leadership Breakthrough!

Before we dive into the survey, take a moment to reflect on where you are in your career—and where you want to go next. This quick intake will help us understand your goals, challenges, and what kind of support would be most valuable for you.

Be honest and open with your answers—this is a judgment-free zone designed to help you gain clarity and take actionable steps toward success.

Ready to get started?

Let’s go!

First Name *

Last Name *

Phone *

Email *

Section 1: Getting to Know You

What is your current job title and industry? *

How many years of experience do you have in your field? *

What are your top 3 career goals for next year? *

Section 2: Career & Leadership Challenges (Pain Points)

Let’s be real—what’s been your biggest struggle when it comes to your career? *

Do you ever feel stuck in your career, unsure of your next move? *

Yes

What’s holding you back from reaching your next career level? (Select all that apply) *

Lack of clarity on career direction

Fear of salary negotiation or self-advocacy

Feeling undervalued or overlooked for promotions

Toxic work environment / workplace politics

Imposter syndrome or lack of confidence

Work-life balance struggles / burnout

No leadership experience but want to step up

What’s the #1 thing you wish you had help with right now? *

How does your current job make you feel?

Fulfilled & Thriving – I love what I do!

Stuck & Uninspired – It’s okay, but I want more.

Burned Out & Frustrated – I need a change ASAP!

Overworked & Undervalued – I feel trapped.

Have you ever stayed in a job that no longer served you because you didn’t know how to leave? *

Yes

Do you feel confident negotiating your salary or asking for a raise? *

Yes, I own it!

No, I avoid it / I’ve never tried but want to learn!

What’s your biggest fear when it comes to career growth?

Section 3: Leadership & Professional Development

Leadership isn’t just about a title—it’s about impact.

Do you consider yourself a leader in your current role? *

Yes

No, but I want to be!

If you had stronger leadership skills, what would that allow you to do? (Check all that apply) *

Earn a higher salary

Be more respected & valued at work

Speak up & be more confident in meetings

Step into a leadership role with ease

Set better boundaries & avoid burnout

What’s your biggest challenge when it comes to leadership?

Section 4: Career Transition & Work-Life Balance

Balancing career growth & personal life can be tough.

Let’s find solutions.

Do you feel like your job is taking over your personal life? *

Yes, I have no work-life balance

No, I manage well

Sometimes, but I want to improve!

Are you currently looking to transition into a new role or industry? *

Yes, actively looking

No, but considering it

Not right now, but maybe in the future

What’s stopping you from making a career transition?

Fear of the unknown

Financial security concerns

Lack of confidence

Not sure where to start

Section 5: Readiness for Coaching & Solutions

You don’t have to figure this out alone.

Let’s build your career strategy together.

If I could help you break through your biggest career roadblock in the next 30 days, would you be ready to take action? *

Yes

I need more information

What type of support would help you the most? *

1:1 career coaching & leadership development

Salary negotiation training & confidence building

Career transition & interview preparation

Group coaching & community accountability

Executive-level leadership coaching

Are you willing to invest in yourself to level up your career & leadership?

Yes, I’m ready

I need to learn more

I’m not sure yet

Final Question

What would success look like for you after working together? *