Name: *required Email: *required Phone: *required
1. How many years of experience in dementia care have you had?
2. What was your last position in dementia care?
How long were you in that position?
3. Do you have personal caregiving experience?
	- Yes No
4. If yes, who was the care recipient? (check all that apply)
	Parent   Spouse   Sibling   Other Family Member   Non-Relative
5. What is your homecare experience?
	- SW RN OT/PT Home Aide
6. Are you employed?
	- FT PT Retired
7. Are you able to invest between $5,000 and $10,000 in this opportunity?
	- Yes No
8. Do you have business experience?
	- Yes No
9. What type business experience?
	- Marketing Director Sales Owner
10. Have you experience in training or teaching others?
	- Yes No
11. How much do you enjoy teaching?
	- 0 - Not Much 1 2 3 4 5 - A Lot
12. What type of training was it?
	- Business Healthcare Other
13. How do you envision being a coach licensee? (check all that apply)
	Career   PT Work   A Business
14. Describe yourself in 300 characters or less.
15. Gender
	- Female Male
16. How did you learn about the StilMee™ Coaching Opportunity?