WBHW New Practitioner Enquiry Form
Name
*
First Name
Last Name
Email
*
example@example.com
Mobile
*
Please enter a valid phone number.
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What modality is your practice?
*
Physiotherapy
Massage
Osteopathy
Chiropractic
Psychology
Counselling
Energy Healing
Hypnotherapy
Other
How long have you been in practice for?
*
< 12 months
1-2 years
2-5 years
5 - 10 years
10 + years
Are you interested in our Geelong West or Ocean Grove clinic space?
*
Geelong West
Ocean Grove
Both
How many days would you like to rent the room for?
*
1 day
2 days
3 days
4 days
5 days
Weekends only
Where do you currently practice from? (all interactions with potential practitioners are held in the strictest confidence and privacy)
*
Do you have a current client base?
*
Yes - I have a full client base who will follow me wherever I go
Yes - I have current clients but there is room to increase my numbers
No - I'm just getting started but I'm confident I will be able to build my list with WOM and other forms of advertising
If you are still building your client base, where do you anticipate the majority of your clients will come from?
Tell us a bit about yourself - who you are, why you do what you do and what motivates you to get up out of bed each morning.
*
What is your vision for an optimal clinic setting and how you see yourself collaborating with a multidisciplinary team?
*
Is there anything else you would like to share or any questions you have for us?
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