1-800-7-ADVICE Take Our Free Guest Tour

Initial Practice Analysis Survey

CONTACT INFORMATION

Please complete this profile as accurately as possible. Your answers can affect the outcome of your Breakthrough Coaching analysis.

(This and all future communications will be kept completely confidential.)
 
How were you referred to Breakthrough Coaching?
Who were you referred to by?
First Name: * : 
Last Name: * : 
Practice Name: * : 
Address: * : 
Address : : 
City * : 
State * : 
Zipcode * : 
Office Phone: * : 
Office Fax: : 
Home Telephone: : 
Email Address: * : 
Confirm Email Address: * : 
 
PERSONAL PROFILE
 
Chiropractic College: : 
Year Graduated: : 
Describe yourself professionally. * : 
 DC Owner  DC Associate  DC Student  CA  Other  
If Other, please explain.
How long have you been in practice? * : 
Describe your practice? * : 
 DC  DC with Rehab  Multidisciplinary Practice  
Marital Status: : 
 Married  Single  Divorced  Widowed
Ages of children:

1.
2.
3.
4.
5.
 
Number of Professionals Employed?

DCs : 
MDs : 
DOs : 
PTs : 
PTAs : 
LMTs : 
Other: : 
 
How many total staff members: * : 
 1  2  3  4  5  6  7  8  9  10  Other  
Other : 
Complete the following based upon your MONTHLY average:
Office Visits per month: : 
New Patients per month: : 
Billings $ per month: : 
Collections $ per month: : 
How many vacation days have you experienced over the last twelve months? * : 
Compared to last year, my income has: : 
 Increased  Decreased  Stayed the same  Unsure  
 
Do you ever feel burned out at the end of the week? * : 
 Yes  No  
Do your marketing and public relations programs attract the type of new patients you wish to see? * : 
 Yes  No  Unsure  
Can your current systems handle the loss, replacement, and training of each of your key staff members? * : 
 Yes  No  Unsure    
Are you confident that your documentation meets or exceeds insurance and regulatory requirements? * : 
 Yes  No  Unsure    
How long would your practice run at its current levels of production without your presence? *
How many months?
Unsure : 
If you do not change anything that you are currently doing, will you be satisfied with where your practice will be five years from now? * : 
 Yes  No  Unsure    
Do you have a “done date” at which you wish to reach financial security? * : 
 Yes  No  Unsure    
What do you consider your #1 practice challenge? * : 
Do you currently work with a practice management firm? * : 
 Yes  No      
If yes, which one?
Have you worked with a practice management firm in the past? * : 
 Yes  No      
If yes, which one?
 
Additional Comments :