*1.Full Name(Required.)

*2.Email(Required.)

*3.Phone Number(Required.)

4.I will be contacting you about your application via text message. If you are located outside of the United States, please leave your WhatsApp or Telegram contact, along with which country you are located in.

*5.What kind of practice do you have (what modality or modalities, general, community, specialty, pediatrics, etc)?(Required.)

*6.How long have you been in practice?(Required.)

*7.How many patients do you currently treat each week on average?(Required.)

*8.What are your fees?(Required.)

*9.In TWO SENTENCES, tell me your story. :)(Required.)

*10.What are the top 3 core challenges in your practice that you want to fix over the next 6 months? What works/what doesn't? What do you feel you need to do better? (please be as detailed as possible).(Required.)

*11.In relation to marketing, what do you feel you need to work on the most?(Required.)

*12.Currently how do you attain the majority of your patients?(Required.)

*13.What is your current financial plan of action?  How are you supporting yourself financially as your practice grows?  ie. A side job, spousal support, savings, etc.(Required.)

*14.What are the largest issues that are more about mindset and disempowering beliefs that you feel you need help pushing through?(Required.)

*15.What are you currently doing, or have done previously, for mindset work?(Required.)

*16.What programs, courses or coaching have you invested in, in the past? How much have you invested in total (estimated)?(Required.)

*17.Where do you want your business and life to be in 12 months from now? Include your desired income.(Required.)

*18.What do you think you need in order to attain your 12 month goals?(Required.)