Tell Me About You & Your Business Dreams

Please fill this out as best as you can. This will help make our first consultation call very effective. If you are unsure on how to answer anything below, that's ok, you can just write UNSURE AT THIS MOMENT.

*This questionnaire is intended for any medical or health care provider that may be interested in business consulting for a cash-based independent medical provider business from MarilynKaminski.com & GodHeals.Me coaching.

Basic info about you and your business goals

Your name *

Preferred Contact Phone Number

Email address *

What is your current role? Title? Check all that apply. *

Tell me what is your big business dream / goal / motivation / passion? Tell me as much as possible about why you are interested in having your own independent medical practice or related business. What strengths do you offer in this big dream? What weaknesses/limitations do you think you may have that may make it difficult to pursue this mission? *

A component of my coaching involves connecting you to God for Divine Wisdom and Empowering you to provide healing and cures for your patients. Please let me know how much you believe God is involved. This does not disqualify you from being a coaching client.

On a scale of 1-10, how much do you believe God is involved with your medical provider skills and abilities and your ability to provide phenomenal results to your patients. *

0 - God is not involved10 - God is the power behind healing

Do you currently own an independent medical or healthcare business? *

Yes

No, but I wish to.

No, I don't prefer to

If so, do you have any employees? List any employee roles you have currently employed.

What is your business name? Or what do you think you want it to be called? *

What type of entity do you currently have? *

Do you know what a PMA entity is (Private Member Association)? *

Yes, I have one.

Yes, but I do not want one.

No, I do not know what a PMA is.

What is your exit strategy for your business or what do you think your future business exit plan will be? *

Work in this business until I decide to close the business.

Sell the business some day.

I have no idea.

Do you want to have cash-based/self-pay patients? *

Yes, I want to be only cash-based. No insurance contracts

Yes, but I would like to take some insurance contracts.

No, I prefer to only have insurance contracts.

I do not know

What type of location / place of service do you need to accomplish your current independent practice goals. Where will you provide your services? *

What is your website URL? Or what do you think you want it to be? *

More about YOU as a business owner

If you currently have your own business, please answer the next few questions. If you do not currently have your own business, you can skip this section.

Tell me what regular responsibilities within your business, that you LOVE

Tell me what regular responsibilities within your business, that you REALLY DISLIKE, but know you need to do to pursue your business dream or goals.

How many hours per week do you work IN your business - this means within the daily operations?

How many hours per week do you work ON your business - this means anything that is considered business seperate from operations...like marketing, financial, goal setting, analyzing metrics, building new product or service lines, etc?

Do you incorporate any intentional faith-based or spiritual practices within your business? If so, describe.

Business Administration

What scheduling software do you currently use? Or desire to use? If unsure, just write "NOT SURE YET" *

What Health Records (EMR/EHR/CRM) software do you currently use? Or desire to use? If unsure, just write "NOT SURE YET" *

What minimal reporting / patient records do you want to provide? Or are required to provide? Describe. *

What payment options or merchant service do you currently use? Or desire to use? If unsure, just write "NOT SURE YET" *

What communication needs will you have or desire to have to communicate with patients? If unsure, just write "NOT SURE YET" *

How will you receive phone calls from your patients? Check all that apply. *

Just my own cell phone. No need for anything else.

Office phone line with basic features, such as voicemail

Office phone line with multi-ring groups or call forwarding options.

No phone calls. Only online meetings.

No phone calls. Only communication through online schedules.

Unsure of my needs yet

Other Other

Do you need help with creating or establishing New Patient paperwork forms or electronic processes? If so, describe what you need help with. *

How do you track your business transactions? Bookkeeping / Accounting system. Check all that apply. *

POS system reports

Basic Excel for transactions

Quickbooks or similar software

I have a bookkeeper and they track all my transactions.

I just give everything to my accountant that they ask for to file my taxes.

I have a CFO and/or accounting team in my business

I don't track any of my transactions and I would love to learn how to do this.

Other

What insurance plans do you have in place or think you need to have in place? *

What State & Local jurisdictions will you generate revenue from AND have employees earning wages? Check all that apply. *

Just my local area

State-wide (that I live and work in)

State-wide (that I don't live and work in)

Multiple States (greater than 1 state) / National

International

Other. Please describe Other. Please describe

Marketing Plan

Who is your target patient (target marketing audience)? Describe your ideal customer. Please describe any demographics that apply to your ideal customer. *

What platforms do you currently marketing your business on? Check all that apply *

Please list out all service types or products you want to sell to your patients. Just a basic list is ok. *

What is your USP (Unique Selling Point)? What makes a patient want to become a patient of yours? *

Any additional information you would like to share with me: