Name: ________________________________ Date: __________________

How do I _______________________________________________________________

______________________________________________________________________

Priority (check one)

• A – I need help from the group today (degree of urgency as well as importance)
• B – This can wait til next month and/or I have other resources for assistance
• C – This can wait and it’s not that important; nice to get to if time
• D – I don’t plan to bring this to the group at this time because __________________

Kind of help I believe I need from TEC: (check one or more)

• Thought partner(s) with whom to dialogue
• Identify where I’m struggling or stuck
• Validate my planned actions
• Challenge my planned actions
• Hear and empathize with my feelings (non judgmental support)
• Clarify action steps to take in next 30 days
• Hold me accountable
• Other ___________________________________

Who do I need assistance from in this group? (check one or more)

• 121 with Gil
• 121 with other member: _________________-

• mini board (2 –3 other members often work with)

• small group (5 – 8 other members – random or topic selection)
• full group (I need the widest range of experience and perspectives – and/or belief that majority will give/receive value from discussion)

• Vistage View  library and best practices
• Other: ___________________________________

What do I need to prepare to optimize the time we spend on this? Topic worksheet; background data – Anything to provide ahead of time?

Notes (including date and status):