Rx90 Program Qualification Application

I am so excited that you are ready to build the practice of your dreams! Please take a few moments to complete this application.

Once you submit your form, I will personally review it – it’s completely confidential – and, if it feels like you would be a good fit for the program, my assistant, Donna, will contact you to arrange a time for us to chat on the phone. We will review your application together and then, if I feel 100% certain that we can work well together, I will offer you a position in the Program! I can’t wait to speak with you one-on-one and get moving towards making your practice profitable, once and for all!

Your Name


Your Email

Phone number

1. How did you hear about Rebecca’s mentorship program?

2. What type of business do you have?

3. How long have you been in business?

4. What was your previous year’s gross income in this business?

5. What is your number one challenge as it relates to building your business?

6. What have you done so far to invest in your business as it relates to growing your business? For example, have you taken any workshops, worked with a business coach, or hired a mentor? What was your experience?

7. Over the next 12 months, how much money would you like to generate in your business?

8. On a scale of 1-10, 1 being “not important at all” and 10 being “critically important,” how important is it to you to accomplish this revenue goal?

9. How serious are you about reaching your revenue goal?

10. Why are you not there yet? What is holding you back? (Be as honest as you can be, please.)

11. On a scale of 1-10, 1 being “not ready at all” and 10 being “totally and completely ready,” how ready are you to have a frank discussion about what’s not working so well in your business?

12. Are you ready to invest in yourself (mentally, emotionally, physically, financially) to make the changes required to reach all your business (and life’s) goals? Are you ready to move outside your comfort zone to reach these goals? If so, why now?

13. How would being a part of Rebecca’s mentorship program change your business and your life?

14. Briefly describe why you are a good fit for Rebecca’s mentorship program.

15. Is there anything else you would like Rebecca to know when considering you for an interview?