First Name

Last Name

Phone *

Email *

What type of provider are you?

Where are you in your business right now?

What’s the biggest challenge you’re facing in your practice right now?

What would success look like for you over the next six months?

Why do you feel drawn to The Practice Rebellion™ right now?

This program requires time, energy, and financial commitment. Are you prepared to invest in your growth if accepted?

If accepted, when would you like to start?

Anything else you’d like Susan to know before reviewing your application?

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By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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