Registration for Life Coaching Please complete the registration form below in its entirety. This will provide context to determine an initial positioning for your coaching sessions. Vision Works Life Coaching & Program Intake Form Vision Works Life Coaching & Program Intake Form First Name * Last Name * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Address I live in... * Hamilton County Butler County Some place else Email Address * Phone Number * Date of Birth * Gender Identity * Male Female Nonbinary Prefer not to say Self-describe Race / Ethnicity * Black / African American White Hispanic / Latino Asian Native American / Alaska Native Native Hawaiian / Pacific Islander Multiracial OtherOther How many children do you have? None 1 2 3 4 5 OtherOther Program Enrollment Elevate & Empower Lay-off-to-Launch Pathways to Prosperity Housing Stability Supports Youth & Family Enrichment Partnerships Intake Date Referral Source Partner Social Media Self Case Manager OtherOther What areas of your life would you like to improve? Career Relationships Health & Wellness Finances Personal Growth OtherOther What are your goals in seeking life coaching? * I am seeking a better paying job or I need to make more money. I am unsatisfied with my life's trajectory. I am unhappy. I am looking for employment or I have been unemployed for a long time. I am interested in being married or finding the right mate. I struggle to maintain relationships. I sometimes have a hard time getting along with people or I have a hard time keeping jobs. I need more education, but I don't know how to start or how to pay for it. I feel unfulfilled or I am trying to rebuild my life. I am a struggling single parent, and I need a support system. I want to start my own business. I want to write a book. I want to re-invent myself. OtherOther Reason for Enrolling Upload Resume Drop a file here or click to upload Choose File Maximum file size: 134.22MB Upload ID Drop a file here or click to upload Choose File Maximum file size: 134.22MB Do you have a drivers license? Yes No Do you have a car? Yes No Are you currently employed? Yes No Current Monthly Income ($) Annual Income 0-$20,000 $20,001-$45,000 $45,001-$65,000 $65,001-$80,000 $80,001-$100,000 $100,001-$250,000 $250,001-$500,000 OtherOther Did you graduate from high school? Yes No Have you graduated from college? Yes No Have you attended college? Yes No Highest Education Level High School GED Some College Associate’s Bachelor’s Graduate Are you interested in attending college? Yes No Employment Barriers Lack of transportation Childcare Justice involvement Skills gap/ I need a credential Housing instability Health issues Needs Support In Job placement Financial literacy Housing Digital skills Entrepreneurship Notes (Case Manager) Credit Score (Baseline) Household Size Housing Status Rent Own Homeless Transitional Food Security Usually have enough to eat Sometimes Often not enough Savings Balance ($) Consent * I consent to participate in Vision Works programs and allow data use for reporting and evaluation. Digital Signature Clear Submit If you are human, leave this field blank.
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