Consultation Request

Step 1 of 8

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Contact Information

Contact Person(Required)

First Last

Job Title/Role(Required)

Organization(Required)

Work Email(Required)

Contact Number(Required)

Website

Preferred Contact Method(Required)

Tell Us About Your Organization

What type of healthcare organization do you operate?(Required)

If "Other", please explain:(Required)

What is the loctaion (city, state) of your organization?(Required)

Are there multiple locations?(Required)

Yes

If Yes, How many location are there?

What services do you currently provide?(Required)

How long has your organization been in operation?(Required)

Less than 1 year

1-5 years

6-10 years

10+ years

Approximately how large is your organization?(Required)

1-10 employees

11-25

26-50

51-100

101-250

250+

Your Current Growth Situation

What is the primary reason you are seeking consulting support? Select all that apply.(Required)

Increase referrals

Generate more qualified leads

Improve business development

Build a referral network

Improve sales performance

Develop a marketing strategy

Strengthen brand positioning

Launch a new service

Enter a new market

Improve CRM/lead management

Build a business development process

Improve client acquisition

Scale the organization

Other:_________________

If "Other" -please explain(Required)

What are your organization's biggest growth challenges right now?(Required)

How are you currently generating new business or referrals? Select all that apply.(Required)

Physicians referrals

Hospital referrals

Health plans/ payers

Community organizations

Networking

Digital marketing

Social media

Paid advertising

Sales/business development team

Existing client referrals

Partnerships

Other:____________________

If "Other" please explain(Required)

How would you describe your current referral pipeline?*(Required)

We don't currently have a formal pipeline

Limited and inconsistent

Somewhat consistent

Strong but needs optimization

Very strong and scalable

Marketing & Business Development

Do you currently have a dedicated marketing or business development function?(Required)

Yes- Internal team

Yes- Outsourced

Both internal and outsourced

Not sure

What marketing/business development systems do you currently use? Select all that apply.(Required)

CRM

Email Marketing

Website analytics

Google Ads

Social media advertising

Content marketing

Referral tracking

Lead scoring

Sale pipeline reporting

None

Other:___________________

"Other" please explain(Required)

How effectively are you currently tracking leads and referrals?(Required)

Not currently tracking

Basic/manual tracking

Somewhat organized

Well organized

Highly automated

Your Goals

What would you like to accomplish over the next 6–12 months?(Required)

What would make this consulting engagement a success for your organization?(Required)

Are there specific growth targets you are trying to achieve? Examples: revenue, referral volume, new locations, admissions, clients, contracts, partnerships, etc.(Required)

How urgent is your need for support?(Required)

Exploring options

Within the next 90 days

Withing the next 30 days

Immediate help needed

Consulting Needs

Which areas are you most interested in discussing with Kirkbrook? Select your top priorities.(Required)

Healthcare Growth Strategy

Business Development

Referral Growth Strategy

Marketing Strategy

Brand Strategy

Lead Generation

CRM & Pipeline Development

Sales Process Development

Partnership Development

Market Expansion

Marketing Automation

Performance Metrics & KPI

Fractional Leadership Support

Have you worked with a marketing or business development consultant before?(Required)

Yes

If yes, what did you like or dislike about the experience?(Required)

Budget & Engagement

Do you have an estimated budget for consulting or growth initiatives?(Required)

Under 2,500

$2,500 - $5,000

$5,000 - $10,000

$10,000 - $25,000

$25,000 - $50,000

$50,000+

Not yet determined

What type of engagement are you considering?(Required)

Growth assessment

Project-based

Ongoing monthly consulting

Fractional leadership support

Not sure - I'd like a recommendation

Who is involved in making the decision to hire a consultant?(Required)

I am the primary decision-maker

Executive leadership

Owner/founder

Board

Multiple stakeholders

Other:__________________

"Other" Please list who is the decision maker for your organization.(Required)

Consulting Details

What would you most like to discuss during your consultation?(Required)

Is there anything else we should know before our conversation?

Preferred consultation timeframe:(Required)

As soon as possible

This week

Withing the next 2 weeks

Within the next month

I'm just exploring options

Preferred consultation format:(Required)

Zoom/Virtual Call

Phone Call

In-Person

Other:__________

"Other" Please explain preferred meeting format(Required)

Final Step

How did you hear about us?(Required)

"Other" Please explain(Required)

Consent(Required)

I agree

By submitting this form, you agree to be contacted by Kirkbrook regarding your consultation request. Your information will be used to evaluate your business needs and communicate with you about potential consulting services.

Kirkbrook Growth Assessment Questionnaire