Practice Development Mentorship Application
Thank you for your interest in working together. I work with a limited number of practices each year to provide personalized mentorship and strategic support. Please complete the application below so I can learn more about you, your practice, and your goals.
Contact Information
Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Practice Name
Practice Website
Instagram Handle
Location (City, State)
About Your Practice
What best describes your practice?
Startup Practice
General Dentistry
Biological Dentistry
Airway-Focused Practice
Cosmetic Dentistry
Pediatric Dentistry
Specialty Practice
Other
How many years have you been in practice?
How many team members do you currently have?
Back
Next
Are you currently:
In Network
Out of Network
Fee-for-Service
Current Challenges
What are the biggest challenges you are currently facing in your practice?
What feels most overwhelming right now?
What have you already tried to solve these challenges?
Your Vision
What inspired you to apply for mentorship?
If we were having this conversation one year from today, what would need to happen for you to feel like this was a huge success?
What are your biggest goals for your practice over the next 12 months?
What are your biggest goals for your life outside of the practice over the next 12 months?
Areas of Support
Which areas would you like help with? (Select all that apply)
Practice Vision & Positioning
Biological Dentistry Integration
Airway Integration
Oral-Systemic Health
New Patient Experience
Patient Communication
Team Training & Development
Leadership
Fee Schedule Optimization
Case Acceptance
Back
Next
Systems & Operations
Startup Support
Marketing & Content Strategy
Referral Network Development
Membership Programs
Hygiene Department Development
Other
Commitment
Why is now the right time for you to invest in mentorship?
What would prevent you from achieving your goals on your own?
Are you prepared to invest time, energy, and resources into implementing changes in your practice?
Yes
No
Final Question
Why do you feel we would be a good fit to work together?
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