Dr. T.D. Wilson

Confidential Questionaire

Confidential DC Coaching Questionnaire and Personal Success Worksheet

Prior to starting a coaching relationship with Dr. Wilson, he requires an initial conversation with a potential client. This ensures you and he are a perfect fit for one another.
Coaching is of such a personal nature that it is essential for both coach and client to be at ease with one another. Your initial conversation is FREE and will include coaching, so that you may get a feel for the process.

Please complete and submit the following questionnaire. This form has been carefully designed to allow Dr. Wilson to become acquainted with you and your situation before your first meeting. By completing this form, you will be "jump starting" your coaching experience. Your answers are strictly confidential therefore we ask that you be brutally honest with both Dr. Wilson and yourself.

Dr. Wilson is committed to HIGHLY personalized coaching. The more detail and specificity, the greater your enjoyment and results will be.
If you are a student and you do not have some of the below information in place, simply write tbc (which means “to be created”). If a specific question asks about your practice, please use your internship as a reflection of that practice. Dr. Wilson will make the transition in the coaching.

First Name:
Last Name:
Email Address:
Best Phone Number to Reach You:
Office Phone:
Full Address:


Your Practice Please check off all aspects of your practice where you feel you need coaching and guidance. Please note Dr. Wilson uses the term “Practice Member” vs. “Patients”.
	Attracting New Practice Members
	Retention of Practice Members
	Clinical Results for Practice Members
	Profitability in Practice, or the Idea of A Profitable Practice
	Reactivating Former Members
	Staff and Team Building
	Passion for Practice
	Systems and Organization
	In-Office Lectures
	Report of Findings Dialogue

Your Financial Situation Please check off the financial concerns and issues on which you feel you need coaching.
	Presenting Fees
	Saving Money - Paying off Student Loans
	Increasing Your Fees
	High Personal Debt Load
	Paying Taxes
	Controlling Expenses
	Establishing Budgets in Your Practice and Life
	Affording Your Lifestyle
	Collecting Fees from Clients/Insurance Companies

Your Personal Life Please identify and check off all areas of your personal life in which you need coaching.
	Procrastination
	Organization and efficiency
	More free time
	A vision of your Ideal Future
	Certainty in your abilities
	Delegation ability
	Fear of rejection
	Fear of public speaking
	More vacations
	Stress levels are constantly high
	Tolerating and “putting up with” too much in your life
	Personal health/exercise lacking
	Want more fun in practice and life - Managing a schedule
Other areas in which you would like coaching Please describe below:
Please list the THREE most important concerns from the list above: 1. 2. 3.
What have you been procrastinating about lately? Can you list 10 things? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
What talents do you have that others may not know about?

What are your current monthly statistics? First 3 months goals:
New Practice Members Patient Visits Monthly Clinic Income Fixed Expenses

What do you consider to be your best strengths?

What do you consider to be your weaknesses?

If you could have your Ideal Practice – What would it look like?

What is the number one obstacle interfering with your success?

How will you know if Dr. Wilson’s coaching is effective?

What are your current days/hours of operation per week?

What are your ideal hours?