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Initial Practice Analysis Survey
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: * :
Chiropractic College: :
Year Graduated: :
Describe yourself professionally. * :
If Other, please explain.
How long have you been in practice? * :
Describe your practice? * :
DC with Rehab
Marital Status: :
Ages of children:
Number of Professionals Employed?
How many total staff members: * :
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: :
Stayed the same
Do you ever feel burned out at the end of the week? * :
Do your marketing and public relations programs attract the type of new patients you wish to see? * :
Can your current systems handle the loss, replacement, and training of each of your key staff members? * :
Are you confident that your documentation meets or exceeds insurance and regulatory requirements? * :
How long would your practice run at its current levels of production without your presence? *
How many months?
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? * :
Do you have a “done date” at which you wish to reach financial security? * :
What do you consider your #1 practice challenge? * :
Do you currently work with a practice management firm? * :
If yes, which one?
Have you worked with a practice management firm in the past? * :
If yes, which one?
Additional Comments :
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