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EXECUTIVE & LEADERSHIP COACHING APPLICATION

Executive coaching is for professionals, entrepreneurs, and leaders who are ready to approach their personal and professional growth with greater intention.

This application helps me understand your current responsibilities, goals, challenges, and what you're hoping to accomplish through personalized coaching.

Basic Information

First name

Last name

Email

Phone

Current Professional Role

Current Challenges & Goals

What prompted you to explore executive coaching at this time?

What's one area of your personal or professional life that feels out of alignment right now?

Coaching Commitment

How would you describe your current willingness and capacity to make changes?

I'm ready to take action and want accountability.

I know change is needed but need help clarifying my direction.

I'm exploring whether coaching is the right fit.

Are you open to reflection, goal-setting, and practical action between sessions?

Yes

I'd like more information

Unsure

What coaching arrangement interests you?

Structured Coaching Program

Individual Coaching Sessions

Unsure.

Commitment & Structure

My rate for 60-minute individual sessions is $150. It may be tax deductible for business owner. Are you prepared to invest financially and commit time to a personalized coaching experience?

Yes, I understand services are private-pay

I would like to explore other options

How did you hear about my practice?

Created by Dr. Ernesha Smith

Holistic Therapist • Somatic Practitioner • Integration Guide

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You don’t have to rush your becoming.