Private Practice Launch Pre-Consult Questionnaire
Answer this form so I can understand your current stage, goals, and the type of support that will serve you best. This helps me recommend the coaching package that fits you and ensures our session is focused, productive, and tailored to your practice journey.
Full Name
*
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
What state are you currently licensed in?
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What is your current license type?
*
LMSW
LCSW
LPT
LMFT
Psychologist
Pre-licensed clinician
Other
If none of the choices apply, what is your current license type?
Where are you in your private practice journey?
*
I have not started yet and need help from the beginning
I am in early planning but have not launched
I recently launched and need support building structure
I have an active practice but need guidance improving systems and direction
If you already have a practice, when did you start?
Briefly describe your practice status (where you are now).
*
What is your desired launch or growth timeline?
*
Within 3 months
Within 6 months
At the beginning of the year
Already launched but need structure
I am not sure
What are your top three goals for working together?
*
What is motivating you to build or strengthen your practice at this time?
*
Which of the following do you currently have?
*
Business name
LLC
EIN
NPI
Business bank account
None of the above
If you already have these items, share any questions or concerns.
Who do you feel called to serve?
*
What specialties or client concerns interest you the most? (You may add all specialties you want.)
*
Trauma
Anxiety
Depression
Couples
Teens
Identity work
Faith based counselling
Other
In your own words, describe the practice you want to build.
*
Do you already use an EHR or scheduling system?
*
Yes
No
If yes, which one?
*
What systems or tools do you want to learn more about?
*
What feels unclear, overwhelming, or confusing in this season?
*
What kind of support helps you feel most successful?
*
Clear step by step instructions
Accountability
Templates and tools
Encouragement and mindset support
Strategy and direction
Other
Do you have any questions you want to discuss during the Strategy Session?
*
Anything else you would like me to know before we meet?
*
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