Practice Building Worksheet
Please fill out as much information as possible so that Dr. Kolt may spot specific trends, areas for professional development and priorities for practice growth.
Thank you for your candid and confidential responses.
Fields marked with (*) are mandatory.
Please list the best times to contact you:
Time Zone: PST MST CST EST
1) Clinical orientation(s):
2) Average length of treatment:
3) Practice goals and objectives:
4) Are you interested in developing:
Managed care exclusively. Cash practice exclusively.
A combination of % Cash and % Managed Care.
5) Do you have a managed care "personal application packet" developed?
YES NO
Would your like to develop one?
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?
13) What software do you use?
14) Do you have a support staff?
15) What is their hourly salary?
16) List any employee benefits provided:
17) How many hours a week do they work for you?
18) Is staff turnover a problem?
19) What is their basic job description?
20) Please list the personal assets that you feel you bring to your practice development:
21) Please list any challenges, concerns or fears that relate to your practice building:
22) What do you enjoy most and least about being in private practice?
23) Name three clinical specialties that you are competent in, enjoy and want to expand your referrals in:
24) On a scale of 1 to 10, please rate yourself in the following areas:
(a) Knowledge of small business development 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(b) Clarity of current business goals 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(c) Understanding the managed care system 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(d) Interest in creating a group practice 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(e) Time management skills 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(f) Goal setting skills 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(g) Effectiveness as a supervisor/delegator/boss 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(h) Doing public speaking and seminars 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(i) Conducting workshops and experiential training 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(j) Professional writing (nonresearch) 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(k) Radio and TV interviews and appearances 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(l) Comfort with high levels of success 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(m) Comfort with risk taking 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
(n) Commitment to reaching your practice goals 1 2 3 4 5 6 7 8 9 10 Current skill level 1 2 3 4 5 6 7 8 9 10 Interest in learning
25) Are there any other questions or issues that you would like me to address?
IMPORTANT: Before submitting this form, please ensure that you have completed the mandatory fields (*). Failure to do so will result in the loss of the information you have entered.
