Pre-Course Survey | Strozzi Institute: Embodied Leadership

Pre-Course Survey

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Please take a few minutes to complete the pre-course survey.

Please Note: After submitting the questionnaire, we will email you your answers for your records. However, if you feel strongly about keeping a record of your answers, it is suggested that you prepare/store your answers in a separate document prior to submission.

Contact ID

Activity ID

Course ID

How true are the following statements?

Others see me as a compelling leader. *

I can build trust with others. *

I am able to use conflict as an opportunity to build relationships (as opposed to creating further problems). *

I have the quality of personal relationships that I want. *

I have the quality of professional relationships that I want. *

I have the ability to shift my own mood. *

I feel my vision/values are aligned in my personal life. *

I feel my work is well aligned with my values. *

I am living the life I want. *

I am comfortable with who I am. *

I feel present in my daily life. *

When under pressure, I am able to act out from intention rather than reaction. *

I am aware of my habits in stressful situations. *

I am able to give constructive, actionable feedback. *

I am able to receive constructive, actionable feedback. *

Which of these represents why you are taking this course? *

Select all that apply

Self Transformation/Growth

Leadership Development

Professional Development

Coach Development

Interpersonal/Teamwork Development

Develop Bodywork/Healing Skills

Other

Current Coaching Status

Only for students of our Somatic Coaching Certification Program

Are you currently working as a coach?

If yes, what type?

Leadership Coaching

Executive Coaching

Personal Coaching

Corporate/Business Coaching

If you are working as a coach are you currently ICF certified?

If yes, what level of ICF certification do you hold?

Please answer the following questions

Name Badge *

How would you like your name to appear on your name badge?

What is your sexual orientation? (Optional)

Lodging *

You are invited to stay onsite during this course. Where will you be staying?

T-Shirt Size

What business sector do you currently work in?

Are you a member of ICF pursuing credit through this course? *

Describe your current personal goals. (i.e., relationships, family, leisure time): *

Describe your current professional goals. (i.e., Job, career, income, contribution): *

Under pressure, what ways do you respond that are effective, and what ways do you respond that are not effective? *

What do you hope this course can offer you? *

List known allergies: *

Will any of your allergies necessitate medical intervention? *

List medications you are taking for physical or psychological conditions: *

List any injuries we should be aware of: *

Dietary Preference (Select all that apply):

Gluten Free

Dairy Free

Vegetarian

Vegan

Nightshade Free

Pescetarian

Physician Name *

Physician Phone *

Emergency Contact *

Emergency Contact Relationship *

Emergency Contact Phone *

In one of our physical practices, it is helpful to get a sense of the heights of the participants in advance. Are you taller than 5'8"? *

I have read and understand the cancellation policy *

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