INTAKE & PRE-SCREENING FORM

Tell Us About Yourself

Thank you for your interest in career coaching.
This coaching experience is designed for emerging healthcare, health science, and health tech professionals (0–7 years experience) who are ready to take strategic, focused action toward career growth, clarity, and higher-earning opportunities.

Please complete the form below.
Submission does not guarantee acceptance.

Section 1: Basic Information
This field is required
A valid email address is required
Section 2: Career Stage
0–1 years
1–3 years
3–5 years
5–7 years
7+ years
This field is required
Recent graduate exploring career options
Early career professional seeking growth or advancement
Transitioning into healthcare, health science, or health tech
This field is required
Section 3: Professional Background
Healthcare (clinical or patient-facing)
Health Science (non-clinical, admin, research, public health)
Health Tech (IT, data, digital health)
Other
This field is required
This field is required
Associate
Bachelor's
Master's
Doctoral
Other
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Section 4: Career Goals & Compensation
Secure my first role
Transition into a higher-paying role
Pivot into a new area (health tech, administration, etc.)
Gain clarity on my next strategic steps
This field is required
This field is required
Not currently employed
Under $35,000
$35,000–$50,000
$50,000–$65,000
$65,000–$80,000
Prefer not to answer
This field is required
$40,000–$55,000
$55,000–$70,000
$70,000–$90,000
$90,000+
I'm not sure yet
Prefer not to answer
This field is required
Section 5: Mindset & Readiness
I am motivated and ready to take strategic action
I need clarity and direction on my next steps
I am open to learning and implementing new strategies
I feel stuck and need guidance to move forward
I am unsure about my direction at this time
This field is required
Section 6: Action & Effort Level
Applied to roles
Updated or revised my resume
Completed courses or certifications
Engaged in networking or outreach
I have not yet taken action
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Strategic career direction and planning
Resume and professional positioning
Role targeting and next-step execution
General guidance
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Section 7: Commitment to Growth
Yes
No
This field is required
Section 8: Final Reflection
This field is required

This coaching experience is built for professionals who are done waiting and ready to move — with clarity, strategy, and real direction.

Your responses go directly to Dr. Thomas before your session. Come ready to act.

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Application Received!

Thank you for completing your intake form.
Your responses have been sent to our team.

You will now be directed to book your Career Strategy Session.