Page 1/2PSC 3546 E (2020-04-01)

Public Service Commission of Canada

Commission de la fonction publique du Canada

Protected B (when completed)

Executive Counselling Services request form

Date of the request (YYYY/MM/DD)

Client number (To be completed by program)

Privacy Notice StatementThe Public Service Commission of Canada is committed to respecting your rights with regard to the protection of the confidential nature of your personal information.

The definition of “personal information” is any information, in any form, about an identifiable individual. Refer to section 3 of the Privacy Act for more details on personal information.

Personal information is used to provide executive counselling services to clients of the Personnel Psychology Centre. It is collected under the authority of sections 11, 30 and 36 of the Public Service Employment Act. Your information may also be used for invoicing and statistical purposes to ensure the quality of services. When used for statistical purposes, aggregate data will be used with no reference to your personal information. Providing your personal information is voluntary, but if you choose not to share your personal information, you may not be able to participate in Personnel Psychology Centre services. Personal information collected by the Personnel Psychology Centre is protected from disclosure to unauthorized persons and agencies subject to the provisions of the Privacy Act. Personal information may be disclosed to third parties, with your written permission, identifying what information will be disclosed and to whom. However, personal information may be disclosed without your consent in certain specific circumstances, as per section 8 of the Privacy Act.

You have the right to the protection of and access to your personal information, and to request corrections where you believe there is an error or omission. You may contact Executive Counselling Services to request corrections.

Personal information is collected and used as described in the Executive Counselling Services Files (PSC PCE 744) and the Assessment by the Personnel Psychology Centre (PSC PCU 025) Personal Information Banks found in the Public Service Commission’s Info Source chapter. Hard-copy and electronic records are retained for 10 years after being declared inactive, and then destroyed. You have the right to file a complaint with the Privacy Commissioner of Canada regarding the handling of your personal information.

Part A. Type of request Please select any of the requests below that apply.

New to Executive Counselling Services

I would like to identify my needs and request services. (Please complete parts A, B and C of this form)

Returning Executive Counselling Services client

I would like to identify my needs and request new services. (Please complete parts A, B and C of this form)Optional:

I would like to work with a new executive consultant that has:

different expertise. Please specify:

a different consulting approach or personal style. Please specify:

I would like to update my account information (contact information, change in employment, change in department or change in classification). (Please complete parts A and B of this form)

Part B. Client information - *Mandatory fieldsLast name* Given name*

City*Preferred official language of correspondence*

Official spoken language*

English FrenchTelephone number (primary)* Telephone number (secondary)

Email (primary)* Email (secondary)

Substantive positionGroup* Level* EX equivalency

level*

Acting group and level (if applicable)

Department or agency (full name)* Branch/Sector (full name)*

Assignment/Secondment position (if applicable)Effective datesFrom (YYYY/MM/DD) To (YYYY/MM/DD)

Group Level

Department or agency (full name) Branch/Sector (full name)

English French No preference

Page 2/2PSC 3546 E (2020-04-01)

Additional information Please provide any additional details to help us prioritize your needs.

Part C. Services requested Please indicate which services you are interested in receiving and provide additional information as needed.Leadership assessment and development

I would like to know my strengths and areas for development.We use a variety of tools and strategies to help you understand your leadership style and recognize your strengths and areas for development.

Leadership assessment tools (360° feedback, simulations, Candidate Achievement Record)

Personality testing (self-knowledge, personality, motives, leadership derailers, values, emotional intelligence)

I would like to develop my key leadership competencies.Bring new focus to your development by identifying potential learning experiences.

I would like to have constructive discussions about my career progression.In consultation with experienced career counsellors/psychologists and executive consultants, you can clarify a strategy for advancing your career goals.

I would like to prepare for an executive selection process.Our coaching and simulated boards can help you be your best during selection board interviews; the in-depth feedback will ensure you're prepared for the actual interview.

General application strategies Expectations of executive selection boards

General board strategies Assessment simulation (i.e. mock board)

Overcoming interview anxiety

Do you know your interview date? Yes, please specify UnknownDoes this process involve an alternate interview format? (presentation, video, group interview) Yes, please specify Unknown

Leadership challenges I would like to explore alternative solutions and approaches to overcome leadership challenges.We will help you meet challenges unique to your career and your workplace, and seek effective solutions to the demanding situations you encounter.

Self-management (coping with stress, performance anxiety,work-life balance)

Relationship management

Organizational awareness (political skills, influence, networking)

Other (please specify)

Diversity & inclusion I would like to discuss particular circumstances (functional limitations, medical condition), that I think may affect my performance during an interview or assessment.In consultation with an experienced assessment accommodation expert, you can discuss your particular circumstances as well as accommodation strategies or approach for your assessment.

I would like to discuss challenges related to diversity and inclusion.In consultation with an experienced psychologist or executive consultant, you can discuss your particular challenges, identify solutions or develop coping strategies.

Part D. Executive Counselling Services use only Financing information

Billing Authorization form with a limit of $

Memorandum of Understanding with a limit of $

Service request with a limit of $

Or No set limit

Client history File status

Active Closed No previous file or historyFormer client number

Former psychologist or executive consultant (coach) on record (initials)

Executive consultant, please specify

Psychologist, please specify