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Practice Breakthrough Assessment
Thank you for taking the time to engage in this assessment process. I value how precious time is and that your engagement with us is a choice.
My intention upon reviewing what you share on this assessment is to thoroughly provide as insightful and beneficial an exchange as possible for you
during our telephone conversation. Dean L. DePice
Practice Name (*)
Please provide Practice Name
Doctor Name (*)
Enter Doctor Name
Date of Birth
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Spouse
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Date of Birth
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Is Spouse a Chiropractor?
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Practice Address
Please enter Practice Address
 
City
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Office Phone
Please enter phone number with area code		 Fax
Please enter phone number with area code
Dr. Cell Phone
Please enter phone number with area code		 Spouse Cell Phone
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Home Address
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City
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Home Phone
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Email (*)
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Who can we thank for referring you?
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Please name any other TLC Members you know
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1. What Chiropractic College did you attend?
Invalid Input		 Year Graduated
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2. Years in your present practice
Invalid Input		 Did you open this practice?
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If no, please explain your "story in practice"
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3. What is your primary adjusting technique?
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4. Do you use X-Rays?
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5. What other forms of tools do you use for assessments?
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6. Do you plan on continuing to practice chiropractic over the next 5-10 years?
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7. Please list names of all Associate Doctors
Name
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Name
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Team Members
Name
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Name
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Name
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8. Are you in fair exchange with the Internal Revenue Service?
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9. Are there any back taxes owed to the government?
Invalid Input		 If yes, how much?
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10. On a scale of 0-10, how do you feel about the competency of your accountant?
(zero being low and 10 being high)
Please enter a score from 0-10
11. Do you pay yourself a set paycheck on a bi-weekly basis, regardless of practice finances?
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12. What are your present practice statistics?
NPs/mo
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PVA
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13. What are your goals for these practice statistics (within the next 6 months)?
NPs/mo
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Invalid Input		 Services
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PVA
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14. What personal strengths do you see yourself bringing to your life?
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15. Does your practice life spill over into your personal life on evenings or weekends? If so how often and explain;
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16. Do you provide weekly Spinal Workshops? (separate & distinct from patient orientation)
Invalid Input		 Other
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17. Do you provide weekly team trainings (45-60 minutes)?
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18. Do you do 1 on 1 weekly accountability meetings with your team?
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19. Have you been a part of any other coaching/management company?
Company Name
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Company Name
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20. How many events do you attend per year?
Invalid Input		 Do you travel for events?
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(list type of event you attend, Chiropractic and otherwise)
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21. What other coaching or technique groups do you regularly train with?
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22. Please write your exact daily practice hours.
  Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
AM
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PM
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23. Gross outstanding debts (please be as accurate as possible)
Personal
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Professional
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24. On a scale of 0-10, 10 being your best score, please assess how you believe you are performing in the following
12 areas of practice and personal life.
Promotions and Marketing
Please enter a score from 0-10		 Science & Philosophy
Please enter a score from 0-10		 Business Planning
Please enter a score from 0-10
New Patient Process
Please enter a score from 0-10		 Patient Financials
Please enter a score from 0-10		 Leadership
Please enter a score from 0-10
Team Driven Practice
Please enter a score from 0-10		 Belief and Mindedness
Please enter a score from 0-10		 Capacity
Please enter a score from 0-10
Balance
Please enter a score from 0-10		 Patient Care and Outcomes
Please enter a score from 0-10		 Retention
Please enter a score from 0-10
25. What is your greatest challenge you are currently experiencing in your practice?
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26. What do you experience as any other challenges you would wish to share with me?
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27. If your dreams were to become true, over the next several years, what would they look like in your life?
Personal
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Professional
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Enter Code Enter Code
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