LWP Mentor Intake Form

LWP Mentor Intake Form

Confidential Practice Evaluation
Name

First NameLast Name
Email
example@example.com
Motivation for one on one mentoring:
Results you are looking to achieve:
Why should we work with you:
What is your mission?
The documents accompanying this transmission contain confidential information that is legally privileged. This Information Is Intended only for the use of the individual or the entity named above. The authorized recipient of this information is prohibited from disclosing this Information to any other party unless required to do so by law or regulation and Is required to destroy after its slated need has been fulfilled. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or other action taken, in reliance on the contents of these document is strictly prohibited. If you have received this (information in error, please notify the sender immediately and arrange for the return or destruction of these documents.
LWP Practice Assessment Form

DOCTOR and CLINIC INFORMATION
Doctor's Name:
Clinic Name:
Birth Date (optional)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dr.'s Age (optional)
Current Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Years in Practice:
Chiropractic College:
Year Graduated:
Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Office Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Fax:
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Doctor's Email:
example@example.com
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status:
Spouse Name:
Name(s) and Age(s) of Children:
Referred By:

LWP Practice Assessment Form

RECENT PRACTICE PERFORMANCE
Practice Statistics for the last 4 full months:

LWP Practice Assessment Form

OPERATIONS
Type of Practice:
Number of Doctors:
If Multi-Doctor, do doctors share all patients or have their own patients?
Percentage of Wellness vs. Symptom-Based Care:
What are your primary techniques?

Current Hours:

Rows	Mon	Tue	Wed	Thu	Fri	Sat	Sun
A.M.
P.M.
New Pt.’s Seen
Report Times

Are you happy with your office hours?
If you could change them anyway you want, how would you change them?

LWP Practice Assessment Form

PERSONNEL
Current Number of Staff:
No. of Full-Time Staff:
No. of Part-Time Staff:
Personnels:
Are there any staff members that you feel are holding you back from growing?
Is your C.A. team energetic and on-purpose?
Does your average C.A. stay with you for 3 years or longer?
Do you use a signed employee office policy agreement?
How often do you do regular team trainings with your staff?

LWP Practice Assessment Form

REGULAR BUSINESS
How long does it take you to adjust the average patient?
Enter number of minutes
How many patients can you adjust in an hour?
Do you want help in reducing your adjusting time?
What is the most number of patients you have ever adjusted in one day?
How many Patients would you like to see on an average day?
Has your practice volume grown at least 10% in the last 12 months?

LWP Practice Assessment Form

PATIENT EDUCATION and REPORT OF FINDINGS
Do you currently use video patient education?
Whose?
Do you use:
Do you do weekly, monthly or quarterly workshops in your office?
Do you do a formal Report of Findings?
Do you do them in group or Individual format?
Do you use a 1 day, 2 days, or 3 day or more day format?
Do you require the spouse to attend the Report of Findings?
Do you require family members to be checked for subluxations?
Do you charge for "family member check-ups”?

LWP Practice Assessment Form

PRACTICE JOYS and DISSATISFACTIONS
What do you enjoy most about your practice?
What do you like the least?
What is your biggest area of frustration?
If you could completely change one thing about your practice what would it be?
If you could re-Invent your practice right now or were to start a new practice with a clean slate, what would it look like? Please describe it as much detail as possible:
How many total weeks of vacation do you take a year?
How many total weeks of vacation would you ideally like to take per year?
Please describe any significant stress factors in or outside of your practice life, such as pending or recent divorce, marital problems, drinking, gambling, or sexual addiction, extramarital affairs, child custody challenges, health problems, malpractice suits, etc:

LWP Practice Assessment Form

GOALS
Please describe your short-term goals for the next 90-180 days:
Please describe your short-term goals for the next 90-180 days:
Please describe your ultimate practice:
Please describe your short-term goals for the next 90-180 days:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

LWP Mentor Intake Form

LWP Practice Assessment Form

LWP Practice Assessment Form

LWP Practice Assessment Form

LWP Practice Assessment Form

LWP Practice Assessment Form

LWP Practice Assessment Form

LWP Practice Assessment Form

LWP Practice Assessment Form

LWP Practice Assessment Form

LWP Practice Assessment Form