OD Masterminds Intake Form

OD Masterminds Intake Form
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Time Zone*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
We’re offering two OD Mastermind cohorts, each capped at 10 ODs. Please review the cohort options and select your preferred group below. Meetings are held quarterly via Zoom.*

Cohort 1: Wednesdays, 12 to 4 PM ET — Oct 15 2025; Jan 7 2026; Apr 15 2026; July 15 2026Cohort 2: Thursdays, 8:30 to 12:30 PM ET — Oct 16 2025; Jan 8 2026; Apr 16 2026; July 16 2026
Trailing 12 month practice's gross revenue:*
Number of providers in your practice:*
Number of non-OD team members:*
Number of locations:*
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?*
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:*

YesNo
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.*

YesNo
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.*

YesNo
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.*

YesNo
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.*

YesNo
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.*

YesNo
Once a year, our Mastermind members come together for an exclusive in-person retreat—an immersive experience that combines professional growth with unforgettable adventure. Whether it’s white water rafting, skiing, hiking in the mountains, or other outdoor activities, these retreats are designed to foster deeper connections, fresh perspectives, and powerful breakthroughs in a setting that inspires growth and creativity. As good as Zoom is, there’s no substitute for the energy, focus, and camaraderie that happen when we’re together in person. This retreat isn’t just about learning—it’s about transforming the way you think, lead, and live while enjoying meaningful experiences with a community of high-caliber peers.
I’m interested in participating in a potential in-person retreat if it were a 2-day experience (not including travel) scheduled over a weekend to minimize disruption to clinical time. Note: Answering “Yes” is optional and not required to participate in the quarterly virtual mastermind meetings.*

YesNo
Any additional feedback you'd like to share about the idea of a Retreat?
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OD Masterminds Intake Form

Management of Expectations