PracticeSmart 2015 Application

PracticeSmart 2015 Application

We are excited that you are interested in this program. Please complete the information below and we'll be in touch soon.
Personal Information
Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
How did you hear about PracticeWorks? How did you hear about this program?
Online + Social Media
Website
LinkedIn Profile
Facebook Profile
Twitter Profile
YouTube Profile
Other Social Media Profiles
Please list any professional profiles that you maintain (Psychology today, Good Therapy, etc)
You + Your Practice
What is your profession?

Marriage & Family TherapistClinical Social WorkerPsychologist / PsyDCoachIntern / StudentOther
Briefly describe the current state of your practice. How did you get started? How long ago? How do you acquire your clients?
If you are a student or intern, or have not yet started a practice, please describe your ideal private practice
What does your perfect practice look like to you?
What have you done to help build your practice thus far? Networking, website, etc.
Do you currently have a business or marketing plan? Have you ever created them?
Have you participated in any business building coaching, classes, courses, etc? Please describe.
What are your specific goals regarding your practice? What has kept you from accomplishing these goals in the past?
What area of your practice are you needing help with right now?
What do you find most challenging about building your practice?
What has been your most rewarding professional accomplishment?
What is your biggest struggle(s) in life? Could this be getting in the way of your practice?
If you could change 3 things in your life or in your practice, what would they be?
PracticeSmart 2015 Retreat
Why are you interested in applying for this program?
What are you most excited about in terms of what this program can offer you?
What are you hoping to accomplish by the end of this program?
Why would you be a great candidate for this program? How do you see yourself contributing to the PracticeWorks community?
If accepted into this program, what would you like to develop most within your practice?
Are you willing to do whatever it takes to achieve your professional goals?
Is there anything else you would like us to know?
Please mark which best describes you

I am considering building my practice soonI am ready now to start building my profitable practiceI have a practice that I want to take to the next level
Should be Empty:

PracticeSmart 2015 Application

Personal Information

Online + Social Media

You + Your Practice

PracticeSmart 2015 Retreat