COPIA Mentoring & Leadership Survey
Your answer
Your answer
Phone Number
Your answer
Your answer
Web site / social media links
Your answer
Your answer
Briefly describe your vision for your work / leadership.
Your answer
What particular skills and information would you most like to learn in order to increase the effectiveness and impact of your work?
Your answer
What is the most significant challenge you are facing now (in terms of your work)?
Your answer
How would you describe your "personal purpose" in the world?
Your answer
What interests you most about participating in this program?
Your answer
How self-directed are you in your learning style?
Your answer
Briefly describe your coaching / leadership style.
Your answer
How do you learn best?
Rank the following in order of most applicable (1) to least applicable (5) in terms of your learning style
Curriculum reading
Individual coaching sessions
Group discussions
Applied learning / homework
When assessing your life in general, how accurate are the following statements?
I have a positive relationship with money.
I truly love my day to day life.
I always live according to my values.
I regularly engage in self renewal practices such as yoga, meditation, journaling, etc.
When it comes to your work and leadership, how accurate are the following statements?
I set ambitious yet realistic goals.
I trust my own judgment when it comes to my work.
I can easily shift my priorities to adapt to changes.
I am not afraid to take risks.
I am frequently overwhelmed by what I have to do.
I struggle with prioritizing and time management.
I am very clear in my vision and calling for my work
I avoid overextending myself.
My work is making a real impact on the population I want to serve.
I have a solid administrative infrastructure (banking, legal, tax, etc.)
I have a strong theory of change.
I have a brand identity.
I have the proper tools and resources to manage clientele.
I have clearly defined program content that I can offer to clients, groups, or organizations.
I feel comfortable building and calling on a network of people.
I willingly go outside my comfort zone to ensure that I succeed in my work.
I have a strategic plan.
There is a personal, social, and environmental component to my work.
I understand that by participating in the COPIA Health Mentoring and Leadership program, I am committing to the following: 1) Attending monthly group calls 2) Participating in regular individual coaching sessions (with 24 hours reschedule notice) 3) a minimum of six months participation. *
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