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Please note that all fields followed by an asterisk must be filled in.
First Name*
First Name*
Last Name*
Last Name*
E-mail Address*
E-mail Address*
What NAME would you like listed for your Coaching Practice?:*
What NAME would you like listed for your Coaching Practice?:*
In what PROVINCE is your practice based?:*
In what PROVINCE is your practice based?:*
Free State
Eastern Cape
Gauteng
KwaZulu Natal
Limpopo
Mpumalanga
Northern Cape
North West Province
Western Cape
What LOCATION do you want listed (e.g. Cape Town, Sunnydale, Pietermaritzburg)?:*
What LOCATION do you want listed (e.g. Cape Town, Sunnydale, Pietermaritzburg)?:*
In what year were you BORN:
What relevant QUALIFICATIONS (other than NIA) would you like listed?:*
What relevant QUALIFICATIONS (other than NIA) would you like listed?:*
Please list any NIA advanced training or VIP coach certification you hold and the year qualified
How would you describe your Coaching NICHE/Speciality if any
Please describe your USP (what sets you apart from other coaches:
What are your Guideline FEES per session?:*
What are your Guideline FEES per session?:*
Less than R200
R200 - R299
R300 - R399
R400 - R499
R500 - R599
R600 - R799
R800 - R999
More than R1000
On application only
Are these fees NEGOTIABLE on a client by client basis?*
Are these fees NEGOTIABLE on a client by client basis?*
Yes
No
N/A
Please give details of any special DISCOUNTS or incentives you offer:
Are you registered with COMENSA?*
Are you registered with COMENSA?*
Yes
No
If you have a WEBSITE, what is the URL?:
In which LANGUAGE(S) are you proficient at coaching?
Via which MEDIUMS are you prepared to coach?
Face-to-Face
Journal@New Insights
Telephone/Skype
Please type your INTRODUCTORY PROFILE as you wish to see it (no more than 100 words):*
Please type your INTRODUCTORY PROFILE as you wish to see it (no more than 100 words):*
By when can we expect to receive a Word document with your DETAILED PROFILE of up to 2000 words?*
By when can we expect to receive a Word document with your DETAILED PROFILE of up to 2000 words?*
Do you have a PHOTO that you wish to feature. If so please submit this separately*
Do you have a PHOTO that you wish to feature. If so please submit this separately*
Yes, I will submit this with my detailed profile (recommended)
No, I'd prefer not to display a photo
If you answered No above do you have a LOGO that we can feature instead?
Yes
No
Do you have any other comments?
Please enter the word that you see below.