Application

Jay Describes the Platinum Coaching Program

PLATINUM APPLICATION

Fill out the form below to find out if you are eligible for the Platinum Coaching program. Once submitted, we will review the application and contact you within 2 business days.

Tell Us About Where You Are Now

Be honest! Remember, we're not concerned with what you've done in the past, but rather where you are today so we can tailor the program to fit your needs.

I regularly use at least one of the strategies you have taught me. (Yes or No)

I have at least one reliable marketing strategy that consistently generates new business for me. (Yes or No)

I have written financial and business goals. (Yes or No)

I have written goals for other areas of my life. (Yes or No)

I regularly take long weekends, vacations, or other time off to "rejuvenate" myself. (Yes or No)

Tell us about your Practice

Rate the following on a scale from 1-5, according to how much of a challenge they are for you:

1 = Extreme Challenge
2 = Very Often a Challenge
3 = Occasionally a Challenge
4 = Rarely a Challenge
5 = Not At All a Challenge

Generating new patients

Increasing # of repeat patients

Raising prices

Structuring my business so it runs smoothly and I don't have to get bogged down in busy work

Personal Income

Please use the following ranges to answer the questions below:

$50,000 - $100,000
$100,001 - $200,000
$200,001 - $300,000
$300,001 - $400,000
$400,001 - $500,000
$500,000+

Personal NET income in the past 12 months:

What would you LIKE for your NET income to be within 3 years

If I continue with my business in the direction it's going I'll be financially independent in 3-5 years. (Yes or No)

Tell us about yourself:

Number of hours you currently work per week?

Number of hours you'd LIKE to work per week?

Number of weeks off you'll take this year?

Number of weeks off you'd LIKE to take each year?

Answer the following questions using the scale below:

O = Often
S = Sometimes
R = Rarely
N = Never

I feel guilty taking time off.

I'm very confident in my ability to hire and train new employees.

I feel guilty about not giving enough time to my spouse, children, or other relationships in my life.

If my school's class reunion was next month, I'd feel excited about going.

Briefly describe why you would be a good fit for the Platinum program:

Please be as specific as you can. The box is small, but it will hold as much as you type into it.

I'd be a good candidate because:

Tell us how to contact you about your application

First Name *
Last Name *

Doctor's Email: *

Best Contact Phone Number: