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Career Optics Client Questionnaire

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					                                       Career Questionnaire

Dear ______________________:

As a first step to working with Career Optics, please complete this Questionnaire and return it via email to
Customercare@worklifeinnovations.com fax it to 1-860-563-6912. You may also send it via the US
Postal Service to: Mary-Ellen Rogers, 912 Silas Deane Highway, Wethersfield, CT, 06109.

PRIVACY POLICY:

Career Optics will not use any information you provide for any purpose other than to provide professional
services directly to you. We do not sell or release any information you provide to any other party,
including your employer, without your request or as required by law.

A note of caution: Please consider whether you want to take the risk of completing this questionnaire at
your workplace in a setting where your colleagues or managers may gain access to your responses. We
will keep your information confidential after we receive it, but email and documents stored on work
computers are often not secure.

DATE THIS QUESTIONNAIRE WAS COMPLETED:

CONTACT INFO:
Name:
Street address:
City:
State:
Zip code:
Home phone:
Work phone:
Cell phone:
Email to which we can send correspondence regarding your work with us:


DEMOGRAPHIC INFO:
Age:
Spouse’s or Partner's name (if married or partnered):
If married or partnered, what is your spouse’s or partner's career?
Number and age of children (if a parent):




                                                     1
Client Questionnaire - page 2




CAREER SATISFACTION:
On a scale of 1 to 10, with 1 being "Least Satisfied" and 10 being "Most Satisfied," how satisfied are you
with your current career?


What would you most like to change about your current career?


CURRENT OR MOST RECENT JOB:
(a) Your title:
(b) Employer and location:
(c) Dates job began and ended:
(d) Approximate compensation:
(e) Primary responsibilities:
(f) Major accomplishments:
(g) Aspects of the job that you most liked and disliked:
(h) Circumstances under which you left the job:


CAREER HISTORY:
For up to five previous jobs that you held in the past, please complete the following sections:


Job 1:
(1a) Your title:
(1b) Employer and location:
(1c) Dates job began and ended:
(1d) Approximate compensation:
(1e) Primary responsibilities:
(1f) Major accomplishments:
(1g) Aspects of the job that you most liked and disliked:
(1h) Circumstances under which you left the job:


Job 2:
(2a) Your title:
(2b) Employer and location:
(2c) Dates job began and ended:
(2d) Approximate compensation:
(2e) Primary responsibilities:
(2f) Major accomplishments:
Client Questionnaire - page 3



(2g) Aspects of the job that you most liked and disliked:
(2h) Circumstances under which you left the job:


Job 3:
(3a) Your title:
(3b) Employer and location:
(3c) Dates job began and ended:
(3d) Approximate compensation:
(3e) Primary responsibilities:
(3f) Major accomplishments:
(3g) Aspects of the job that you most liked and disliked:
(3h) Circumstances under which you left the job:


Job 4:
(4a) Your title:
(4b) Employer and location:
(4c) Dates job began and ended:
(4d) Approximate compensation:
(4e) Primary responsibilities:
(4f) Major accomplishments:
(4g) Aspects of the job that you most liked and disliked:
(4h) Circumstances under which you left the job:


Job 5:
(5a) Your title:
(5b) Employer and location:
(5c) Dates job began and ended:
(5d) Approximate compensation:
(5e) Primary responsibilities:
(5f) Major accomplishments:
(5g) Aspects of the job that you most liked and disliked:
(5h) Circumstances under which you left the job:
Client Questionnaire - page 4




SKILLS:
What are the top three skills that you offer an employer?




What can you do easily that other people find difficult?




What is difficult for you that others seem to find easier?




EDUCATION:
Please list all education attained.


What have you enjoyed studying?


What have you disliked studying?




HOBBIES:
How do you like to spend your leisure time?




SPIRITUALITY:
Do you have religious or spiritual beliefs that you want to integrate into our work together? If so, please
share them with us below.




FAMILY BACKGROUND:
What is/was your father's career?
Did he like his career?
What is/was your mother's career?
Did she like her career?
What types of careers do other significant family members have (brothers, sisters, others who influenced
you)?
Client Questionnaire - page 5




GOALS FOR OUR WORK:
Career development can be divided into five main areas:
1. Self-assessment - evaluation of interests, personality, values.
2. Research - evaluation of the job market.
3. Personal marketing - job search, small business or consulting marketing, or promoting oneself with
potential employers or clients.
4. Advancement - Polishing interpersonal effectiveness / emotional intelligence / leadership ability to
move ahead in your career.
5. Personal development - Attaining greater satisfaction in such areas as work / life balance or achieving
personal goals beyond traditional career "success."
What are your goals for your work with Bridgeway?
1.


2.


3.


4.


5.


Of all the goals listed above, what is most important to you to accomplish through your work with
Career Optics?
Client Questionnaire - page 6




PREVIOUS PROFESSIONAL ASSISTANCE:
Have you ever invested in professional career and/or personal development services before?
With whom?
Were the results helpful?
Why or why not?



REFERRAL INFO:
Who referred you to Career Optics?




OTHER:
If there is anything else that you would like us to know prior to our beginning to work together, please
share that with us here.




Thank you! We look forward to working with you. After you return the Questionnaire, a Career
Optics counselor will contact you within two business days to discuss our services and to give you
an opportunity to ask questions.

				
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posted:1/18/2012
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