KOLT CONSULTING

Practice Building

Consultation Worksheet

This worksheet will provide us with an overview of your practice. Please fill out as much as possible so that we may spot specific trends, areas for professional development and priorities for practice growth. Thank you for your candid responses.

Please be sure to keep a copy of this worksheet
BEFORE you submit it.


First Name:
Last Name:
Practice Name:
Mailing Address:
City:	State:

Province:

Country:

Zip Code:

Postal Code:

E-Mail:

Website:

Phone:

FAX:

Type of License:

Years licensed:

Age:

Years in private practice:

Best time to
contact you?:

Day(s): Time(s):

#1) Clinical orientation(s):

#2) Average length of treatment:

#3) Practice goals and objectives:

#4) Are you interested in developing:

Managed care exclusively
Yes No

Cash practice exclusively
Yes No

A combination of % Cash % Managed Care

#5) Do you have a managed care "personal application packet" developed?

#6) About how many managed care panels are you on?

#7) Describe your managed care experiences:

#8) Practice statistics:

#9) Marketing and Advertising avenues you have used and the results:

#10) Where do your referrals come from?

#11) What types of new referral sources would you like to develop?

#12) Do you have a computer?

Yes No

#13) What software do you use?

#14) Support staff availability and costs:

Do you have a support staff?

Yes No

What is their hourly salary?

List any employee benefits provided:

How many hours a week do they work for you?

Is staff turnover a problem?

Yes No

What is their basic job description:

#15) Please list the personal assets that you feel you bring to
your practice development:

#16) Please list any challenges, concerns or fears that relate to your practice building:

#17) What do you enjoy most and least about being in private practice?

#18) Name three clinical specialties that you are competent in, enjoy
and want to expand your referrals in:

#19) Please rate yourself and your skills in the following areas:
(on a scale of 1 to 10)

Knowledge of small business development
current skill level
interest in learning
Clarity of current business goals
current skill level
interest in learning
Understanding the managed care system
current skill level
interest in learning
Interest in creating a group practice
current skill level
interest in learning
Time management skills
current skill level
interest in learning
Goal setting skills
current skill level
interest in learning
Effectiveness as a supervisor/delegator/boss
current skill level
interest in learning
Doing public speaking and seminars
current skill level
interest in learning
Conducting workshops and experiential training
current skill level
interest in learning
Professional writing (nonresearch)
current skill level
interest in learning
Radio and TV interviews and appearances
current skill level
interest in learning
Comfort with high levels of success
current skill level
interest in learning
Comfort with risk taking
current skill level
interest in learning
Commitment to reaching your practice goals
current skill level
interest in learning

#20) Are there any other questions or issues that you would like me to address?

Thank You