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Coaching Client Intake Questionnaire

Please complete this questionnaire as detailed as possible so that we can better serve you and your team!

This survey should take you around 10-15 minutes to complete.  Please make sure you get a confirmation screen before closing the window. 

Click the button below to start. Don't stop until you get to a screen that tell you, "You've completed this assessment."

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Practice Information

Here, we will gather general information about your practice.

Question 2 of 30

Practice Name:

Question 3 of 30

Practice City and State:

Question 4 of 30

Owner Doctor's Name(s):

Question 5 of 30

Was your practice a start up or acquisition:

A

Start Up

B

Acquisition

Question 6 of 30

When did you Start Up or Assume Ownership of your practice?

Question 7 of 30

How many operatories do you have currently outfitted?

Question 8 of 30

Can you add any additional operatories?  If so, how many additional?

Question 9 of 30

What do you utilize for Metric Reporting?

A

Divergent Dental

B

Dental Intel

C

Practice by Numbers

D

I don't utilize any of these.

Opinions and Goals

Here, let's explore how you feel about your practice and what you want to see happen.

Question 11 of 30

What is the primary goal that you would like to achieve with coaching?

Question 12 of 30

Was there a specific instance or occurrence that motivated you to reach out for help? If so, what?

Question 13 of 30

What aspect or aspects frustrate you the most at the practice?

Question 14 of 30

What would you most like to change at your practice, if you could only change one thing?

Question 15 of 30

So that we can better serve you, what would your practice look like in a year for you to call working with DPH a success?

Question 16 of 30

What do you feel are your greatest weaknesses as a practice owner?

Question 17 of 30

Is there anything else you can think of that you would like to share so that we can better serve you?

Question 18 of 30

If we asked your team what they think the biggest issues at the practice are and how you are as a leader...what do you think they would say?

Team Information

Here, we will gather information about your team.

Question 20 of 30

Including yourself and all doctors, how many people are on your team?

Question 21 of 30

How many associate doctors do you have?

Question 22 of 30

How many Dental Hygienists?

Question 23 of 30

How many dental assistants?

Question 24 of 30

How many administrative people on your team?

Operational Information

Here, we will gather information about how you operate. 

Question 26 of 30

What Practice Management Software do you use?

Question 27 of 30

What Procedures do you mostly perform in office and not refer out to specialists? (select all that apply)

(Select all that apply)
A

Surgical Extractions

B

3rd Molar Extractions

C

Single Tooth Implants

D

All on X Treatment

E

Molar Endo

F

Premolar/Anterior Endo

G

Band and Bracket Ortho

H

Invisalign or other clear aligner therapy

I

Phase I Orthodontic Treatment

J

Botox

K

Periodontal Surgery

L

Lasers in Hygiene

Question 28 of 30

What procedures do you mostly refer out to specialists? (select all that apply)

(Select all that apply)
A

Surgical Extractions

B

3rd Molar Extractions

C

Single Tooth Implants

D

All on X Treatment

E

Molar Endo

F

Premolar/Anterior Endo

G

Band and Bracket Ortho

H

Invisalign or Other Clear Aligner Therapy

I

Phase I Orthodontics

J

Periodontal Surgery

Question 29 of 30

Which of the following do you currently have implemented and in operation currently? (select all that apply)

(Select all that apply)
A

Monthly Team Meetings

B

Regular One on One Meetings with Team Members

C

Occasional All Day Meetings during the Year

D

Planned Social Functions for the Team other than a Holiday Party

E

An Office Manager

F

Leads (A Leadership Team)

G

A Communication App (slack, private FB page, etc.)

H

Online Scheduling

I

Documents or Photos of Proper Room Setups

J

Mission and Vision Statements

K

Core Values Statement

L

Brand Promises Document

M

Standards of Protocol for hygiene visits. (what x-rays, what diagnostics, etc.)

N

Intraoral Cameras in each Operatory

O

End of Day Checklist for Clinical Team

P

End of Day Checklist for Admin Team

Q

Checklist for Equipment Maintenance (autoclave, milling units, spore testing, flushing lines, etc.)

R

A Bonus System

S

Daily Production Goals

T

Morning Huddles

U

Checklists for Training and Onboarding New Hires

V

Phone Skills Guidelines

W

Phone Call Recording and Review for Training

X

Guidelines for collecting payments and how much is expected and when

Y

Monthly running and working of the AR

Z

Monthly running and working of the Insurance Aging

AA

Utilization of a service to negotiating and optimizing insurance participation

AB

Reviewing Cases with Hygienists and other Doctors to calibrate consistent diagnosis

AC

A scripted patient experience document

AD

Guidelines on what diagnostics are taken on New Patients

AE

System for Unscheduled Treatment Follow up

AF

A "Scoreboard" for tracking important office metrics

AG

Monitoring of Phone calls and Reviewing with the team

Question 30 of 30

Which of the following owner tasks have you delegated to a team member or service? (i.e. you are no longer responsible for)

(Select all that apply)
A

Payroll

B

401k Reconciliation

C

Bookkeeping

D

Credit Card Reconciliation

E

Bank Deposits

F

Opening Mail

G

Scanning Invoices

H

HR Documentation for New Hires

I

Paying Bills

J

Ordering Clinical Supplies

K

Ordering Office Supplies

L

Writing Clinical Notes

M

Writing Lab Slips

N

Performance Reviews

O

Handling Interpersonal Conflict

P

Interviewing Candidates

Q

Troubleshooting Equipment Issues

R

Troubleshooting IT Issues

S

Writing Narratives for Insurance Appeals

T

Conducting Meetings

U

Planning Team Events

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