Individual Empowerment Plan Questionnaire
Please complete the form below to get your Individual Empowerment Plan (IEP) from The Self Esteem Doctor Academy.  This plan is a *GENERAL GUIDE* to help you choose the correct resources in our academy to BEST serve your personal needs.

Your completed plan will be emailed to you. Be sure to check your spam folder or add to your contacts so you receive your plan.

You can expect to receive your recommended class(es) within 1-2 business days.  We will include a brief description of the class as well as a clickable link so you can easily access the class from the email and get started on your self-esteem building journey right away!

Thank you for choosing The Self Esteem Doctor Academy.
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Email *
Empowerment Plan Questionnaire
Your email address is required above, please fill out all additional information below.
Parent/Adult First Name *
Parent/Adult Last Name *
Parent/Adult Phone Number *
First and Last Name of person who the IEP is for *
AGE of of person who the IEP is for *
Which of the follow best describes you? *
The Self Esteem Doctor is NOT a psychology service.  It is a coaching service using Neuro Linguistic Programing and other holistic coaching tools.  The advice provided by The Self Esteem Doctor should NOT replace advice from your mental health provider. *
This form may be modified from time to time to be sure that we are able to get all the information we need to make the BEST recommendations for you. *
The person who this IEP is for is...(Check all that apply) *
The person who this IEP is for usually seem to...[Check all that apply] *
When dealing with others, the person who this IEP is for is often... (Check all that apply) *
The person who this IEP is for...(check all that apply) *
The person who this IEP is for is best described as... (This question helps to determine the age level of resources that will be recommended) *
What type of service do you feel is best for the person who this IEP is for? (Not all services listed are available year-round, but your response will be considered carefully in our recommendation(s)) - Select one or more... *
Please add any other descriptions, stories, and/or examples that you think will help The Self Esteem Doctor Academy to recommend the best resources for the person for whom this IEP is being created. (HOWEVER, If you have highly sensitive information to disclose, please do not include it here.  In that case we ask that you schedule a 15-minute consultation instead of completing this form. Extremely sensitive cases may need to be referred to a licensed therapist or psychologist for an advanced level of care.)
What is/are your overall goal(s) for this person? How will you know that this program/plan has been successful?  In other words, how will know that you/he/she has improved? What changes do you want/expect to see? *
I understand that I will receive my recommended IEP via email from within 24-48 hours (may take longer on weekends). It is best to add this email to your contacts to avoid having it go to your junk/spam folder. *
I understand that this plan is a guide to selecting the right resources and courses from TSED Academy.  I realize that there are no guarantees and that this plan is a general recommendation based on the questions I answered above.  If the person who the IEP is for is dealing with diagnosed (or undiagnosed) psychological issues, our primary recommendation is that he or she be under the guided care of a licensed mental health professional. By submitting this complimentary request for guidance in selecting academy resources, you are stating that you understand these terms and that you are over the age of 18.   Please sign your legal name below. [Typing your name represents your electronic signature on this form.] *
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