OD Masterminds Intake Form
Name
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First Name
Last Name
Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Time Zone
*
Please Select
Eastern
Central
Mountain
Pacific
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Choose the cohort whose meeting time you can reliably commit to for the full year:
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Tuesdays, 11:00 AM – 1:00 PM ET, Dates: 2/24/26, 4/14/26, 6/23/26, 8/25/26, 10/27/26, 1/5/27
Thursdays, 2:00 PM – 4:00 PM ET, Dates: 2/26/26, 4/16/26, 6/25/26, 8/27/26, 10/29/26, 1/7/2027
Trailing 12 month practice's gross revenue:
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Number of providers in your practice:
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Number of non-OD team members:
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Number of locations:
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If we're having a conversation 24-36 months from now, what has to have happened in your life, personally and professionally, for you to feel happy about your progress and for the investment in this mastermind to have been worth it?
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Management of Expectations
I don't want there to be any surprises. Having been in a mastermind for years, I have found these traits and conditions to be invaluable to grow and gain max value out of a mastermind.
My personal income from all sources is >$250,000 & I'm willing to make both a financial and time commitment to be in an accountable, honest, and transparent group of my peers with the collective goal of helping each other achieve a level of success we aspire to reach, led by an experienced facilitator & consultant:
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Yes
No
I understand that my mastermind is counting on my participation and the value I bring to the group and will honor these calls as a "non-negotiable rock" on my calendar. Barring extreme and emergency situations, I understand that if I demonstrate a truant nature in the group, I'll be asked to leave the group.
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Yes
No
I understand that utter and brutal honesty is paramount in any relationship, including a mastermind, and I commit to not only giving honest feedback but receiving it from my group.
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Yes
No
Knowing that numbers tell a numerical story, are unemotional and don't lie, and are a lagging indicator of the inputs that I have made in my business, I'm comfortable being transparent with all the numbers of my practice to my cohort.
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Yes
No
Trust is critical in any relationship. It's easy to break, and hard (if not impossible) to repair. I understand that some of the greatest breakthroughs in life and business can happen when I'm most vulnerable with myself and my peers, but that vulnerability won't happen unless everyone in the group trusts each other in totality. Because of this, I agree that everything that is shared within my Mastermind is confidential and will not be shared outside my group.
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Yes
No
I understand that there is a very big difference between 'wanting' and 'willing.' Almost everyone 'wants' to be successful. Very few are 'willing' to do the steps necessary to achieve the level of success they desire. In that spirit, I understand that accountability significantly increases my chances of following through on action items that are in alignment of my goals & intentions and commit to being held accountable to my group through a transparent accountability system.
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Yes
No
Submit
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