Career Coaching Intake Form

*Information collected on this form is strictly confidential and is used to support the career coaching relationship as well as to measure the impact of our career coaching services*

Basic Information:

First Name *

Middle Initial

Last Name *

Address 1 *

Address 2

Address Type

City *

State/Province *

Country *

Zip *

Phone *

Phone Type

Alternative Phone

Alt. Phone Type

May we contact you via text on your mobile phone? *

Yes
No

Email *

How did you hear about the program? *

If Other/Personal Referral, please describe. (Or enter N/A) *

Current MassBioEd Program Involvements (Select all that apply): *

None
Career HUB Workshop (ie: You Belong in Biotech, Life Sciences Careers, What the Heck is Biotech? etc.)
Life Sciences Apprenticeship Program
Pre-Apprenticeship Program
BioTeach/ACCESS
College to Career Pathways
Professional Training Courses
Life Sciences Workforce Conference
Other:

If other please specify:

Are you currently participating in any of the following industry training programs? *

No
Gloucester Biotechnology Academy
Just A Start Biomedical Program
JVS Biotechnology Pathway
Lab Central Ignite Career Forge
Bioversity Program

Birth Date *

// (mm/dd/yyyy)

Gender *

Preferred Pronouns:

Race/Ethnicity *

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Hispanic/Latino
Mixed Race
Other
Prefer not to say

If other, please specify here:

Are you a Veteran? *

Educational Information

Highest Education Level *

Other Education Level (if applicable):

Are you a current student enrolled in an academic institution? *

Yes - 2 Year Associates
Yes - 4 Year Bachelors
Yes - Undergrad Cert.
Yes - Graduate Student
No - Not currently attending

If you are attending college, are you currently receiving any of the following forms of financial support? *

Financial Aid Grants
Financial Aid Loans (Subsidized/Unsubsidized)
Financial Aid Work Study
Scholarships (include all merit-based, private, and other)
N/A

If applicable, would you like help applying for financial aid (FAFSA)? *

Yes
No
N/A

Please list any colleges attended and any degrees/certificates earned.

Employment Information:

Employment Status: *

Employed Full-Time
Employed Part-Time
Not Employed

*If not employed - Complete the following information for Most Recent Employment.*

Current or Most Recent Employer Name. *

Job Title: *

Start Date: *

End Date (if previous employer):

What is/was your current hourly wage? *

How many hours do/did you work on average for this employer? *

Are you receiving any of the following benefits through your employer? *

Health Insurance
Flexible Spending Account or Health Savings Account
Paid Time Off
Tuition Reimbursement
Retirement Plan
None
Other:

If other, please specify:

If you are currently not working, are you receiving unemployment benefits? *

Yes
No

Will you now or in the future require sponsorship for employment visa status? *

Yes
No

Career Coaching Information:

Which of the following are you interested in learning more about? (Select all that apply) *

Life Sciences/Biotech training programs
Life Sciences/Biotech college degree programs
Life Sciences/Biotech Jobs

Why are you interested in exploring a career in the life sciences/biotech? *

What are your professional and career goals for the next year? *

What are your professional and career goals for the next five years? *

What are your 3-5 greatest strengths or assets? *

What obstacles/challenges do you face in trying to achieve those goals? *

How can I, as your career coach be most helpful to you? *

What is your meeting preference for coaching sessions? (Check both if applicable) *

In-Person
Virtual (Zoom)

Which times of day are you able to meet for our coaching sessions? (Select all that apply) *

Morning (8am-11am)
Lunchtime (11am-1pm)
Afternoon (1pm-4pm)
Evening (4pm-6pm)

Would you be interested in joining a weekly coaching group? *

Yes
No

In order to provide the most quality coaching service would you be willing to take a survey/assessment of your skills, interests, and values? *

Yes
No

Career Coaching Service Agreement:

Please read the Career Coaching Service Agreement: MassBioEd is committed to providing diverse, equitable, and inclusive quality programs and services that meet the life science industry demands. By agreeing to initiate Career Coaching Services as part of the Life Sciences Career HUB you are acknowledging that specific services will be provided by the coach as outlined in a finalized Individual Career Plan (ICP) agreed upon by both client and coach. It will be made explicit in such plan specific, measurable, attainable, relevant, and timely action steps. It is the client’s responsibility to attend scheduled coaching sessions and be accountable for the execution of said steps. It is the client’s right to terminate, pause, or change the direction of services at any time upon initiation of career coaching. Coaching services may also be terminated at any point if a client no longer meets the requirements of services or is not making reasonable progress towards their goals. As part of MassBioEd’s commitment to quality services as well as the mission to provide continued and improved services to our community we ask for your participation in a Service Engagement Survey which will ask information for our Program Outcomes Report. The purpose of this report will be to assess MassBioEd’s ability to continue providing and improving services to individuals. You acknowledge that by acknowledging below, you are granting MassBioEd staff permission to send you the survey to your email and/or reach out to you and obtain such information at the following timepoints – 3 months, 6 months, 1 year – since the start of service. In addition, you agree to complete and submit the survey within a timely manner upon receipt. Information provided will be held confidential and will not be used in a way that either promotes or denies future participation in any service or program offered through MassBioEd. On behalf of the Life Sciences Career HUB Team, we thank you for engaging and supporting MassBioEd’s mission to build a sustainable life sciences workforce. We hope to continue to inspire and illuminate your career journey.

Please check below that you are in agreement with the Career Coaching Service Agreement written above. *

I Agree

Would you be willing to sign a release form for MassBioEd to verify information from your employer or training provider after you are hired/placed? *

Yes
No

*Submission of this intake form does not guarantee immediate initiation of services. Your application may be added to a waitlist depending on availability of services.*

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Career Coaching Intake Form

Basic Information:

Educational Information

Employment Information:

Career Coaching Information:

Career Coaching Service Agreement: