Mansio Collective Membership Application Name * First Name Last Name Email * Phone * (###) ### #### Type and number licensure in Illinois * Your professional website (if you have one) How long have you been practicing SINCE getting fully licensed in your discipline? * Please tell us about your clinical specialty and interests. What kind of clients/patients do you work with? * For mental health providers, what would you say is your preferred clinical orientation? For all other providers, please tell us more about your philosophy/approach to treatment? 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? https://www.mansiocenter.com/mansio-manifesto Do you already have your own practice or are you looking to start one? What type of practice do you have (or are looking to create)? * In-person Virtual Hybrid For space rental, which option are you interested in? * Full-time rental Daily rental Postal address rental For daily rentals, 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 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 Which of the Mansio Collective offerings are you potentially interested in? Free monthly consultation groups Discounted billing services Discounted website design Discounted business consulting 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!
