<%@ Language=Inherit from Web site %> Coaching Application
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Coaching Application
Home Page
For more information about my coaching program, please click here.  Then, when you are ready to start your journey, come back to fill out the following application.


ALL fields are required. 
Failure to fill out  the form in it's entirety will forfeit your application.

After you submit your application, hit the BACK button on your browser to return to this page and then click this link to continue.
 

First Name
Last Name:
Email Address:
Office Phone:
Full Address:
Your Practice
Please check off all aspects of your practice that you feel you need coaching and guidance. Please note that I use the term “Practice Member” vs. “patients”.
Attracting New Practice Members
Retention of Practice Members
Results for Practice Members
Profitability in practice
Reactivating Former Members
Staff and team building
Passion for practice
Systems and organization
In-office lectures
Report of Findings dialogue
Your Financial Situation
Please check off the financial concerns and issues on which you feel you need coaching.
Presenting Fees
Saving money
Increasing your fees
 High debt load
Paying taxes
Controlling expenses
Establishing budgets in your practice and life
Affording your lifestyle
Collecting fees from clients/insurance companies
Your Personal Life
Please identify and check off all areas of your personal life in which you need coaching.
Procrastination
Organization and efficiency
More free time
A vision of your Ideal Future
Certainty in your abilities
Delegation ability
Fear of rejection
Fear of public speaking
More vacations
Stress levels are constantly high
Tolerating and “putting up with” too much in your life
Personal health/exercise lacking
Want more fun in practice and life
Other areas in which you would like coaching
Please describe below::
Please list the THREE most important concerns from the list above:
What have you been procrastinating about lately? Can you list 10 things?
What talents do you have that few, if any, see?

What are your current monthly statistics?
New Practice Members
Patient Visits
Monthly Clinic Income
 Fixed Expenses
What do you consider to be your best strengths?

Please explain why you are interested in coaching with me:

If you could have your Ideal Practice – what would it look like?

What is the number one obstacle interfering with your success?

How will you know if our coaching is effective?
What are your current days/hours of operation per week?
 Once your application is received it will be thoroughly reviewed and I will be contacting you via email to schedule your FREE Coaching Call.
After you submit your application, hit the BACK button on your browser to return to this page and then click this link to continue.

 

Please verify your primary Email: