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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.
Practice Name
(*)
Please provide Practice Name
Doctor Name
(*)
Enter Doctor Name
Date of Birth
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Spouse Name
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Spouse Date of Birth
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Is Spouse a Chiropractor?
Yes
No
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Practice Address
Please enter Practice Address
City
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State
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Zip
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Practice Phone
Please enter phone number with area code
Practice Fax
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Dr. Cell Phone
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Spouse Cell Phone
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Home Address
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City
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State
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Zip
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Home Phone
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Email(s)
(*)
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1. Who can we thank for referring you?
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2. Please name any additional TLC Members you know
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3. What Chiropractic College did you attend?
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Year Graduated
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4. Years in your present practice
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Did you open this practice?
Yes
No
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If no, please explain your "story in practice"
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5. What is your primary adjusting technique?
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6. Do you have an X-Ray unit on premises?
Yes
No
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7. How routinely do you take x-rays?
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8. What other forms of tools do you use for assessments?
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9. Do you plan on continuing to practice chiropractic over the next 5-10 years?
Yes
No
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10. Please list names of all Associate Doctors
Name
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Name
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11. Team Members
Name
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Zone or Function
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Years/Months Employed
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Hours per week
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$/Hour
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Name
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Zone
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Years/Months Employed
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Hours per week
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$/Hour
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Name
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Zone
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Years/Months Employed
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Hours per week
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$/Hour
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12. Are you in fair exchange with the Internal Revenue Service?
Yes
No
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13. Are there any back taxes owed to the government?
Yes
No
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If yes, how much?
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14. 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
15. Do you pay yourself a set paycheck on a bi-weekly basis, regardless of practice finances?
Yes
No
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16. What is your monthly overhead?
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17. What are your
present
practice statistics?
NPs/mo
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OVs/mo
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Services/mo
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Collections/mo
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PVA
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DVA
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% NP Conversions
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18. What are your
goals
for these practice statistics (within the next 6 months)?
NPs/mo
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OVs/mo
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Services/mo
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Collections/mo
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PVA
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DVA
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% NP Conversions
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19. What personal strengths do you see yourself bringing to your life?
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20. Does your practice life spill over into your personal life on evenings or weekends?
Yes
No
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If yes, how often and explain
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21. Do you provide weekly Spinal Workshops?
(separate & distinct from patient orientation)
Yes
No
Other
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Other
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22. Do you provide weekly team trainings (45-60 minutes)?
Yes
No
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23. Do you do 1 on 1 weekly accountability meetings?
Yes
No
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24. Have you been a part of any coaching/management company?
Company Name
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# of years
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Company Name
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# of years
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25. Are you presently coaching with any company?
Yes
No
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Coaching Company Name
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26. What other coaching or technique groups do you regularly train with?
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27. How many events do you attend per year?
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Do you travel for events?
Yes
No
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(list type of event you attend, Chiropractic and otherwise)
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28. Please write your exact daily practice hours.
Monday
Hours/AM Session
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Hours/PM Session
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Tuesday
Hours/AM Session
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Hours/PM Session
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Wednesday
Hours/AM Session
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Hours/PM Session
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Thursday
Hours/AM Session
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Hours/PM Session
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Friday
Hours/AM Session
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Hours/PM Session
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Saturday
Hours/AM Session
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Hours/PM Session
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29. Gross outstanding debts (please be as accurate as possible)
Personal
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Professional
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30. 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
New Patient Process
Please enter a score from 0-10
Team Driven Practice
Please enter a score from 0-10
Balance
Please enter a score from 0-10
Science & Philosophy
Please enter a score from 0-10
Patient Financials
Please enter a score from 0-10
Belief and Mindedness
Please enter a score from 0-10
Patient Care and Outcomes
Please enter a score from 0-10
Business Planning
Please enter a score from 0-10
Leadership
Please enter a score from 0-10
Capacity
Please enter a score from 0-10
Retention
Please enter a score from 0-10
31. What is your greatest challenge you are currently experiencing in your practice?
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32. What do you experience as any other challenges you would wish to share with me?
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33. 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
(*)
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