Registration Form for Private Practice VIP Day with Roxanne Francis, Fri. Sep 29, 2023.
If you are here, it's because you have expressed an interest in learning more about starting and running your very own Private Practice. 
Please go ahead and complete this form, and once registered, we will take your payment to secure your spot and so that we can move towards making your dream come true!
*PLEASE NOTE: This session will be recorded. By signing below, you consent to being recorded and understand that the recording will be used for future training purposes and social media assets by Roxanne Francis Social Work Professional Corporation. 
Email *
First and Last Name *
Phone Number *
Address (Including Province & Postal Code) *
Website & Social Media Handles *
Are you currently a Mental Health Clinician? *
What are your current credentials? *
Are you currently in a private practice (full or part-time)? *
What interests you about my Private Practice VIP Program? *
What do you hope you gain from participation in this program? *
Has anything prevented you from starting your Private Practice? *
What are you currently doing to push your goals forward? (Saving, Google, Free Webinars, Daydreaming, Hiring a Coach, Working with a Mentor, etc.) *
What is your preferred population to work with?  If unclear, please type "not sure". *
In what area do you feel you need the most support? *
On a scale of 1-10, how motivated are you to make this happen? *
Last On My List
Extremely Motivated
What resources do you already have to help you achieve your goals? (i.e. support from people, contacts, personal knowledge, skills, money, time etc). * *
Dollars & Cents: There are only 10 Private Practice VIP spots available, and spots are filling up quickly. Do you have income coming into your business or funds available to invest 4 figures in the growth of your business right now? Please explain. *
Payment Type: *
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