The Academy Enrollment Form

The Academy Enrollment Form
Full Name*

First NameLast Name
Full Address*
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
What is your profession license type and specialty?*
State(s) Licensed in?*
City and counties you plan to provide services in?*
Type of private practice you are starting? (primary care, psych, specialty, etc.)
Main setting of your private practice (office, house calls, facilities, etc.)
$5001-$7,500$7501-$10,000More than $10,000
One paymentTwo paymentsThree payments
I have no business experienceI have a little business experienceI have general business experienceI am a current or former business owner and have business experience
Yes, full timeYes, PRN or part timeNo and looking for employmentNo and not currently looking for employment
TuesThursFriday3pm-5pm EST4pm-6pm EST5pm-7pm EST6pm-8pm ESTSaturday (between 10am-12pm EST only)
FacebookInstagramLinkedInTwitterTik Tok
What is your Facebook name to be added to the private facebook group? Please copy and paste the link OR type your name exactly as it appears on Facebook or paste your Facebook profile link.
YesNo
YesNo
Do you currently have a registered business that you will be using to operate your private practice? If yes, what is the name of business?
Do you have a collaborative physician or medical director or do you require one? (if required by any state you are licensed in)
YesNoI plan to be a hybrid practice and accept insurance and cashI do not plan to accept insurance but I want to be credentialed
What are three main things you want to learn about during this consulting and coaching program?
What are some things you need to overcome in the process of starting your practice/business?
Why do you feel like this is the best time to start your private practice?
Should be Empty: