English Coaching - Intake Self- Assessment

Authentic journeys – Cross Cultural Coaching

Intake Coaching forms

Jennifer Kumar, MSW, CC, Cross-Cultural Coach E-mail: [email protected]

Web: http://authenticjourneys.info

Authentic Journeys Intake & Welcome Packet (Oct. 2011) Page 1

Welcome to coaching. Happy to meet you- please share a little about yourself!

Directions: Fill out the document on the computer and e-mail it to me at [email protected] or print it out, fill it in and bring it to your appointment with me. The information you provide to me on this form is confidential. Name:

Address:

City, State, PIN CODE:

Phone:

(Corporate Clients can put their business contact information.)

E-mail Address:

Birthdate: Age:

Where did you hear about my services?

Have you experienced any kind of English coaching service previously? YES NO

If so please share what about the experience was helpful or what you wish was different:

How long are you looking to contract for services? (these time frames are negotiable)

1-3 months 3-6 months 9-12 months

mailto:[email protected]






These questions may be a bit hard to answer, but if you would like to see or hear examples of the kinds of tutoring I do, I have created a series of podcasts and videos. Here are the links Videos: http://tinyurl.com/youtubetutor Podcasts: http://www.CinchCast.com/jennifer-kumar To be eligible for English conversational coaching, you must already have a basic understanding of English, English Grammar, Vocabulary and can hold simple conversations. Is this true or false? How long have you been learning English? How many months or years? What is your mother tongue? How often do you get to speak English? Who do you normally speak English with? Is it only in limited settings? In which mediums are you exposed to English? (Circle all that apply) TV - Magazines – Newspapers – Radio – Internet – Others ____________________________ Have you had an English tutor before? Yes NO If yes, what were some of the things that you liked about how your tutor helped you? What frustrates you most about learning English?

What have been some of your major achievements in learning English?






Please rate yourself and your English ability. Not Good OK Best

Speaking 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10

Please share why you rated yourself as you did with Speaking: Do you want to work on speaking skills – YES or NO? What solutions have you tried before? What has been helpful? What has not worked? Do you have any thoughts on how you can improve speaking skills? How can I support you?

What is your overall confidence in using English IN PERSON with others?

Not Good OK Best In person confidence 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 Please share why you rated yourself as you did:






What is your overall confidence in using English OVER THE PHONE with others?

Not Good OK Best Phone Confidence 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 Please share why you rated yourself as you did:

Please rate your ability to listen to English conversation. Not Good OK Best

Listening 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10

Please share why you rated yourself as you did with listening: Do you want to work on listening skills – YES or NO? What solutions have you tried before? What has been helpful? What has not worked? Do you have any thoughts on how you can improve listening skills? How can I support you?






Please rate reading ability in English. Not Good OK Best Reading 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 Please share why you rated yourself as you did with Reading:

Do you want to work on reading skills – YES or NO? What solutions have you tried before? What has been helpful? What has not worked? Do you have any thoughts on how you can improve reading skills? How can I support you?

Please rate your ability to write in English.

Not Good OK Best

Writing 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10

Please share why you rated yourself as you did with Writing:

Do you want to work on writing skills – YES or NO? What solutions have you tried before? What has been helpful? What has not worked? Do you have any thoughts on how you can improve writing skills? How can I support you?






What are the top three to five concerns you have with your English learning progress at this time? 1. 2. 3. 4. 5.

What are two or three goals you’d like me to help you with?

How long do think you will need to work with me to achieve your goals?






Signature page

Please sign this page as an agreement between you and I that we will work together to the best of our abilities to achieve your goals! (*Note if you decide to print out the document, print only this page with signature and return it. Please e-mail the entire document to me at [email protected]. Please use the subject line “English Coaching Forms from YOUR NAME”) Upon us starting the rest of our work together, a few other intake forms will be required to fill out. Thank you! I am eager to walk with you on your life’s Authentic Journey! Jennifer Kumar __ Client’s Printed (or typed) Name Coach’s Typed Name Client’s Signature Coach’s Signature Date Date

mailto:[email protected]

Documents

English Coaching - Intake Self- Assessment