SECTION 1. PRACTICE BACKGROUND

1. How long have you been a practice owner? *

Less than 1 year

1–3 years

4–7 years

8+ years

2. In what areas are you most looking to improve and grow? *

Leadership & team culture

Financial performance & profitability

Reducing clinical hours

Marketing & patient growth

Systems & processes

Other

Check all that apply

Other

3. How many days per week do you currently work? *

1–2 days

3–4 days

5+ days

4. How many days per week would you ideally like to be working? *

1–2 days

3–4 days

5+ days

5. How did you hear about us? *

Referral

Social media

Website/Google search

Event/Speaking engagement

Other

SECTION 2. COACHING & LEADERSHIP READINESS

6. Are you prepared to invest in yourself (time, money, resources, and follow-through) to achieve your personal and practice goals? *

Yes

Unsure

7. Are you ready for coaching? *

Yes

Not yet

8. Do you consider yourself coachable? *

Yes

Open to improvement

9. How often does your team interrupt you with questions that could be answered without your input? *

Constantly — it feels like all the time

Occasionally — sometimes

Rarely — minimal interruptions

10. Would you like to decrease your clinical hours while increasing your personal income? *

Yes

Open to it

11. Are you happy with your current income? *

Yes

Haven’t thought much about it

12. If you had access to proven tools to grow your practice, reduce clinical time, and increase income, would you commit to putting in the work? *

Yes, absolutely

Possibly, depending on the commitment

13. Do you currently have a system or strategy for recruiting and retaining great team members? *

Yes

Somewhat

14. How would you rate your leadership skills? *

Excellent

Strong but room to grow

Developing

Needs improvement

15. Have you built a leadership team that shields you from unnecessary daily stresses in the practice? *

Yes

In progress

16. How many hours per week do you dedicate to working on the business (CEO time) versus in the business? *

0 hours

1–3 hours

4–5 hours

6+ hours

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Full Name

Phone

Practice Address

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