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

Invalid Input

Is Spouse a Chiropractor?

Yes No Invalid Input

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

Please enter phone number with area code

Dr. Cell Phone

Please enter phone number with area code

Spouse Cell Phone

Please enter phone number with area code

Home Address

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City

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State

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Zip

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Home Phone

Please enter phone number with area code

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 Invalid Input

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 Invalid Input

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 Invalid Input

10. Please list names of all Associate Doctors

Name

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Name

Invalid Input

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

Invalid Input

$/Hour

Invalid Input

Name

Invalid Input

Zone

Invalid Input

Years/Months Employed

Invalid Input

Hours per week

Invalid Input

$/Hour

Invalid Input

Name

Invalid Input

Zone

Invalid Input

Years/Months Employed

Invalid Input

Hours per week

Invalid Input

$/Hour

Invalid Input

12. Are you in fair exchange with the Internal Revenue Service?

Yes No Invalid Input

13. Are there any back taxes owed to the government?

Yes No Invalid Input

If yes, how much?

Invalid Input

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 Invalid Input

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

Invalid Input

Collections/mo

Invalid Input

PVA

Invalid Input

DVA

Invalid Input

% NP Conversions

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18. What are your goals for these practice statistics (within the next 6 months)?

NPs/mo

Invalid Input

OVs/mo

Invalid Input

Services/mo

Invalid Input

Collections/mo

Invalid Input

PVA

Invalid Input

DVA

Invalid Input

% NP Conversions

Invalid Input

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 Invalid Input

If yes, how often and explain

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21. Do you provide weekly Spinal Workshops? (separate & distinct from patient orientation)

Yes NoOther Invalid Input

Other

Invalid Input

22. Do you provide weekly team trainings (45-60 minutes)?

Yes No Invalid Input

23. Do you do 1 on 1 weekly accountability meetings?

Yes No Invalid Input

24. Have you been a part of any coaching/management company?

Company Name

Invalid Input

# of years

Invalid Input

Company Name

Invalid Input

# of years

Invalid Input

25. Are you presently coaching with any company?

Yes No Invalid Input

Coaching Company Name

Invalid Input

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 Invalid Input

(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

Invalid Input

Tuesday

Hours/AM Session

Invalid Input

Hours/PM Session

Invalid Input

Wednesday

Hours/AM Session

Invalid Input

Hours/PM Session

Invalid Input

Thursday

Hours/AM Session

Invalid Input

Hours/PM Session

Invalid Input

Friday

Hours/AM Session

Invalid Input

Hours/PM Session

Invalid Input

Saturday

Hours/AM Session

Invalid Input

Hours/PM Session

Invalid Input

29. Gross outstanding debts (please be as accurate as possible)

Personal

Invalid Input

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

Invalid Input

Enter Code(*)

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Practice Breakthrough Assessment