Get Started on Your Way to Online Learning Success!

First name

Last name

Address

City

State StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistric of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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Email Address

Cell phone

Time zone Time zoneEasternCentralMountainPacific

Age

How did you find out about online learning success coaching?

What school/university do you attend?

What is the length of the university term? What is the length of the university term? 6 week 8 week 10 week 12 week Other

What are your strengths when it comes to online learning?

What are your biggest struggles with online learning? Check all that apply. What are your biggest struggles with online learning? Check all that apply. Time management Self-esteem Verbal communication Written communication Procrastination Organization Planning/thinking ahead Lack of motivation Reading comprehension Notetaking Compulsive perfectionism Technical Issues/LMS navigation Outside work commitments Outside personal issues Other

What is motivating you now to seek online learning success coaching?

Do you use an organizer, planner, or calendar? Yes/No field Do you use an organizer, planner, or calendar? Yes/No fieldYesNo

What else would you like me to know before we schedule a complimentary meeting?