Please provide your full name, your mobile phone number, and your BEST email address.

First Name *

Last Name *

Phone *

Email *

When is your birthday? *

Mailing Address *

Your Professional Designation(s): *

How did you hear about the Mastermind? *

Referral (if referred, please share their name)

Event

HBA

Organically (found our website)

Referral (if referred, please share their name)

Business URL/Website & social media handles *

Tell us a little bit more about your niche. Who do you serve and what is the biggest problem you solve for your ideal customer? *

What were your 3 biggest accomplishments in the last 2 years? *

What were the 3 biggest obstacles you had to overcome or are still struggling with in the past 2 years? *

Who or what are your biggest obstacles to reaching your current personal and business goals? *

If you could change 3 things in your business or life in the next 12 months what would they be? *

What IMPACT and LEGACY would you like to leave behind? *

What is your long-term vision for your business? *

Were you nominated by a current or past Mastermind member?

What are your personal goals over the next 10 years? *

How many team members do you currently have and what are they? *

Why are you a good candidate for the Mindshare Mastermind - what would you bring to the group? *

What was your approximate gross revenue for the last 3 years? *

This year
Last year
2 years ago

(This is CONFIDENTIAL)

What was your approximate NET Income (profit) for the last 3 years? *

This year
Last year
2 years ago

(This is CONFIDENTIAL)

Please rank your Most Profitable revenue sources: *

1 on 1 patient visits
Group Programs
Online Courses
Supplements
Publishing/Media Appearances
Other

Are there any new products or services you’d like to offer in the next 12 months? (e.g. publish a book, start a podcast, build a funnel, launch a summit)? *

How would you rate the last 3 years of your business? *

Stuck. Not getting where I planned. Need to get some forward momentum.

Slow Roll. I’m making slow progress. I wish it was faster.

Average. I’m growing as fast as any similar business.

Growth mode. I’m personally growing. My business is growing. The future is bright.

Rocket Ship. I’m leaving a wake! I'm moving so fast.

What other business trainings are you currently participating in? ( HBA MM) *

What types of business trainings have you done in the past? *

Anything else you would like to share with our coaches? *

I would like more information about my business partner (or CEO/COO/CMO/CFO) joining Mastermind with me to get even more aligned to grow my company MM *