Coaching Application Form Coaching Application Form This application will take approximately 15 minutes to complete and includes reading and signing the Coaching Agreement at the end. Your Email Your Team/Organization Name Your Name Your Phone Number Best time/day to contact you 1. What is your role or job title? 2. Please describe the structure of your team. Your “team” may be anything from the organizational or departmental level to your colleagues you interface with day-to-day. (e.g., 3 MDs, 2 nurses, 2 techs, working 9a-5pm; staff changes each shift versus staying the same) 3. What health care setting are you in and what patient population do you serve? (e.g., hospital, ICU, rural/urban, community, outpatient, public health) 4. Which Past the Pandemic program(s) have you attended? Please check all that apply: Coping in COVID (ECHO series, formerly Mental Wellbeing for You & Your Patients)Beyond BurnoutOnline Canvas CourseI have trained with Laura McGladrey or Responder Alliance in some other setting. 5. Please list 2-3 challenges or stressors that are affecting your team right now: 6. What draws you to this program? 7. Do you hope or plan to include any of your team members or colleagues into the Coaching sessions? If so, whom? 8. Please thoroughly read the Coaching Agreement (images below) and type your name in the box to represent your signature. *You can download the Coaching Agreement here: Coaching Agreement 9. Do you have any other questions about the Coaching & Support program? We will be in touch within 3 business days to discuss your application. Please note you will be paired with a Past the Pandemic coach based on availability and fit. Thank you for your interest and patience, and we look forward to connecting with you. Thank you for submitting your application.