Coaching Application
Congratulations on being nominated for The Practice Growth Institute Membership! Please fill out the form below prior to your scheduled application review.
Full Name
*
First Name
Last Name
Best Phone Number
*
Best E-Mail Address
example@example.com
Tell us about your business. Rate the following on a scale from 1-5, according to how much of a challenge they are for you.
Generating New Patients
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Delegating $10/hour tasks
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Taking off as much time as I’d like
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Answer following questions by typing your responses into the appropriate fields.
How many hours do you work per week?
How many weeks will you take off this year?
Previous 12 months of practice collections:
Previous 12 months net income:
Check all the following that are true for you (be honest!):
I have written goals for all areas of my life
I am confident in my ability to grow my practice
I have a team worth investing in
Answer these questions using one of the following responses: Often, Sometimes, Rarely, or Never.
I feel stressed when I take time off:
Please Select
Often
Sometimes
Rarely
Never
I worry that I’m not giving enough time to my spouse, children, or other relationships in my life:
Please Select
Often
Sometimes
Rarely
Never
If my school’s class reunion was next month, I’d feel excited about going:
Please Select
Often
Sometimes
Rarely
Never
Answer the following questions by typing your responses into the fields provided.
Do you plan to sell your practice?
If so, when?
Have you ever been in a coaching relationship? Please share your experience:
Briefly describe why you feel like you’re a good candidate for the program:
If we met 3 years from today, what would it take for you to be extremely happy with your progress, both personally and professionally?
Submit Coaching Application
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