Your Name *

Your Email *

Business Name *

Business Address *

Website *

Your Role *

Are you interested in participating for 6 months or 12 months? *

Business Information

Is your KAP business a Private Practice or a Clinic? *

Private Practice

Clinic

How would you describe the size of your clinic? *

Small

Medium

Large

How many KAP patients/clients are you seeing per month? *

How many KAP patients/clients could your practice see per month if operating at full capacity? *

What is your practice/clinic's annual revenue? *

(This helps us understand the scale of your practice as we tailor the group experience.)

Where do you envision your clinic/practice in 12 months? *

(What specific goals are you aiming for in the near future?)

What is your long-term vision for your practice/clinic over the next 3-5 years? *

(How do you see your practice/clinic evolving or growing during this time?)

How many team members are currently part of your clinic? *

(This helps us understand the size and structure of your organization.)

What are your primary goals for participating in this Mastermind group? *

(Example: Are you looking for business growth strategies, operational insights, or community support?)

How would you describe the current state of your clinic in terms of business operations, patient care, and overall success? *

(Example: What are you most proud of, and what do you feel needs improvement?)

What specific challenges or obstacles are you facing that you hope to address through this Mastermind? *

(Example: Staffing, patient acquisition, operational efficiencies, or scaling your practice?)

What unique strengths, experiences, or expertise can you bring to the group to help others succeed? *

(Example: Do you have a proven system, innovative ideas, or industry insights you'd be willing to share?)

What does success look like for you after participating in this Mastermind group? *

(Example: Increased revenue, enhanced patient satisfaction, streamlined operations, or personal development as a leader?

Are you interested in leading an Accountability Group as a moderator? *

Yes

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