Mansio Collective Membership Application Name * First Name Last Name Email * Phone * (###) ### #### Type and number licensure in Illinois * In what city in Illinois do you reside? * Your professional website (if you have one) Please list your highest degree in the field of mental health, school and graduation date. * How long have you been a practicing clinician SINCE getting fully licensed? * Please tell us about your clinical specialty and interests. What kind of clients do you work with? * What would you say is your preferred clinical orientation? * Please familiarize yourself with Mansio Manifesto. On the scale of 1 to 10, how strongly do you resonate with it? What do you resonate most/least with? * Link for Mansio Manifesto: https://www.mansiocenter.com/mansio-manifesto What type of private practice do you have (or looking to create)? Fully virtual Fully in person Hybrid Which time blocks are you interested in renting? * Mondays 8:00AM-2:30PM Mondays 2:30PM-9:00PM Tuesdays 8:00AM-2:30PM Tuesdays 2:30PM-9:00PM Wednesdays 8:00AM-2:30PM Wednesdays 2:30PM-9:00PM Thursdays 8:00AM-2:30PM Thursdays 2:30PM-9:00PM Fridays 8:00AM-2:30PM Fridays 2:30PM-9:00PM Saturdays 8:00AM-2:30PM Saturdays 2:30PM-9:00PM Sundays 8:00AM-2:30PM Sundays 2:30PM-9:00PM None of the above--I am a 100% virtual practice Do you already have your own practice or are you looking to start one? * Are you interested in potentially outsourcing your billing to the Mansio Center at a discounted price? Yes No Maybe--I would like more info Are you interested in free monthly consultation groups with fellow clinicians at the Mansio Center? Yes No Maybe--I would like more info Are you interested in discounted professional development opportunities designed to deepen your skills in working with trauma? Yes No Maybe--I would like more info Are you interested in discounted business consulting offering designed to help establish a new private practice or optimize an existing one? Yes No Maybe--I would like more info How soon are you looking to start renting office space (if applicable)? As soon as possible Within the next month Within the next 2 months Within the next 3 months Within the next 6 months Please feel free to provide any other info about yourself that you think might be helpful or feel free to ask questions Thank you! We will review your application within the next 3 days and will get back with you. Thank you for your time to apply!
