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Pre-Registration Form: AC34 CIS XCC4 SML Healthcare

Small Cohort Leadership Coaching: Culturally Inclusive Customer Experience | Healthcare Edition

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Question 1 of 18

Q1. Which country are you based in?

Question 2 of 18

Q2. What is the name of your healthcare organisation?

Question 3 of 18

Q3. Which best describes your organisation?  

(Select one)

A

Hospital or health service

B

General practice or primary care provider

C

Specialist or allied health provider

D

Pathology, imaging or diagnostic service

E

Aged care or community care provider

F

Primary Health Network

G

Government health department or agency

H

Other

Question 4 of 18

Q4. Please provide your contact number. 

This is so I can reach you if I need to clarify anything about your pre-registration. 

Question 5 of 18

Q5. Tell me a little about your role. 

Briefly describe what you do and your responsibilities relating to the visitor experience.

Question 6 of 18

Q6. Who are you pre-registering for?

A

Myself

B

Someone else from my organisation

Question 7 of 18

Q7. If you’re pre-registering for someone else, please provide their name and role.  

If this doesn’t apply, enter “Not applicable”.

Question 8 of 18

Q8. Which areas are within your or the proposed participant’s responsibility or influence?

(Select all that apply)
A

Patient or customer experience

B

Practice or service operations

C

Frontline patient services (including reception, bookings or contact centres)

D

Clinical or allied health leadership

E

People, culture, learning or capability

F

Community or consumer engagement

G

Other

Question 9 of 18

Q9. What has prompted your interest in this program at this particular time? 

Question 10 of 18

Q10. What would you most like to gain clarity about through the program?  

(Select all that apply)
A

Which parts of the customer experience require attention first

B

Where frontline staff may need greater confidence, capability or support

C

Which procedures, processes or information practices may need review

D

Where management expectations, guidance or authority may need clarification

E

What evidence or information may still need to be gathered

F

Where further support or investment may be warranted

G

What a focused path forward could look like for my organisation

H

Something else

Question 11 of 18

Q11. What customer-experience challenge or concern would you most like to explore during the program?

If nothing specific immediately comes to mind, enter “Unsure” or “Not Applicable”. 

Question 12 of 18

Q12. Which best describes how you or the proposed participant could use the findings from the program?  

(Select one) 

A

I can directly make or approve relevant changes

B

I can recommend or influence relevant changes

C

I can contribute findings to others who make or approve relevant changes

D

I’m still determining how the findings could be used within my organisation

Question 13 of 18

Q13. Will you be able to access current examples, staff perspectives, procedures, feedback or other information about the customer experience during the four-week program? 

(Select one) 

A

Yes – I expect to have good access to relevant information

B

Yes – although my access may be limited in some areas

C

I’m not yet sure what information I’ll be able to access

D

This may be difficult in my current role or circumstances

Question 14 of 18

Q14. Are you or the proposed participant available to attend all four live coaching sessions? 

As places are limited, availability for all four sessions is preferred.

A

Yes – I expect to be available for all four sessions

B

Probably – although I need to confirm one or more dates

C

No – I already know I'm unavailable for one or more sessions

D

I'm pre-registering on behalf of someone else and need to confirm their availability

Question 15 of 18

Q15. Are you the decision-maker for approving or confirming payment for this program?  

(Select one) 

A

Yes

B

No

C

I share the decision with someone else

Question 16 of 18

Q16. Do you have any accessibility needs you’d like me to be aware of? 

If this doesn’t apply, enter “Not applicable”.

Question 17 of 18

Q17. Do you have any questions, or is there anything else you’d like me to know when reviewing your pre-registration?  

If nothing specific immediately comes to mind, enter “Not Applicable”.

 

Question 18 of 18

Before you submit 

 

On the next page, you may be asked to confirm your contact details and communication preferences. 

 

To receive important updates about your pre-registration, enrolment opportunities and cohort reminders, please select "Subscribe to our email list" if that option appears. 

A

I'm ready to submit my pre-registration

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