Elevate Life

Mentoring Application

Purpose:

The purpose of this application is to help Richard get a sense of who you are, your life experience, the vision of where you want to take your life/work and the results you hope for through a mentoring relationship. Upon completion of this application, you will get an email with a link to book a mentoring Discovery Session with Richard where we will get to know each other more and make a decision about working together.

Directions:

Please complete the application as completely as you can prior to booking your Discovery Session. Your answers will help us clarify and determine if we are a good match and how I can be of service to you in creating your best life. Be brief and answer the questions that apply to you as best you can. If need be, we can go deeper into these questions when we meet.

Complete and submit the form in one sitting as the information is not saved until the form is submitted. When you have finished filling out the form, click Submit at the bottom of this page to send your answers to Richard. You will also receive a copy by email.

NOTE: All personal information is strictly confidential and only for the use of our discovery. The information is kept on a highly secure server and will not shared with anyone except by your express permission. If there are sensitive items that you would rather not write here but are important to evaluate our mentoring relationship, you can bring them up verbally in our conversation.

* is a required field

Personal Information

* First Name:

* Last Name:

* Email:

* Cell Phone

* City

* Country

* Date of Birth: (Day/Month/Year)

Time of Birth (if known)

* City/Country of Birth

Life Questions

10.

What is missing from your life? What would make your life more fulfilling?

11.

Please indicate your satisfaction with the following general life categories where '5' is very satisfied and '1' is not satisfied. If the category does not apply, just leave your response blank.

	1	2	3	4	5
Relationship - significant other/romance
Relationship - family and friends
Finances / money
Health and Fitness
Personal Growth and Learning
Fun and recreation
Physical environment
Business/Career
Spiritual Growth/purpose/meaning

12.

If there was a secret passion in your life, what would it be?

13.

What do you consider your role to be in your community? In your country? In the world?

14.

What accomplishments must, in your opinion, occur during your lifetime so that you will consider your life to have been satisfying and well lived - a life of few or no regrets?

15.

If you could devote your life to serving others — and still have the money and lifestyle you need — would you do it? How would it look?

16.

Do you believe in God or in the concept of a higher power? If so, describe the most useful and empowering aspects of your relationship with God? If not, what reference point do you use?

Life Challenges

17.

What are you tolerating in your life?

18.

What are your top three life challenges?

19.

Please indicate if you have any of the following emotional issues and the level on to which the issue or challenge impairs you. If the issue or category does not apply, just leave your response blank.

	1 (slight)	2	3	4	5 (severe)
Fears or phobias
Anger issues
Betrayal / Trust issues
Feelings of Rejection
Guilt
Shame
Resentment
Stress
Addictions
Anxiety
Panic attacks
Overwhelm
Trauma
Post traumatic Stress Disorder
Abandonment Issues
Depression
Grief and loss
Loneliness

20.

In the box below, summarize any other emotional challenges or elaborate on the areas above which you feel are significant and need more explanation.

Mentoring Relationship Questions

21.

* Which of the following mentoring focuses would be the best fit for you?

Life Mastery - to elevate my overall experience of life, taking it to new heights!

Leadership & Legacy Mastery - to elevate my leadership capacity and the impact I have in the world

Shadow Mastery - to learn and develop my capacity to facilitate the transformation of 'shadow' within myself and/or your clients.

Business Mastery - To develop and grow my business

Other (please describe):

22.

What are your top three goals that you would like to address through mentoring?

23.

What would you most like to learn in your mentoring relationship?

24.

What qualities or skills are you looking for in a mentor?

25.

What questions do you have for Richard about mentoring?

26.

Are there any other comments you would like to make? Please write additional comments in the box below.

Contact Richard

About Richard

Richard Schultz assists leaders in unlocking their true potential, authentic power and inner wisdom to create extraordinary, high impact lives. Courses, life mentoring and dialogue with Richard can help you live your legacy and build capacity to thrive with change!

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