Connected Minds: a monthly networking event for Mental Health Professionals

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Please complete the form below. The information required must be completed each time to register you for the event. The rest of the information is to get to know you and your work in the mental health field. If you have previously completed this information, or do not wish to disclose, please feel free to leave blank.

If you have any questions, please reach out via email: info@lightcollectiveandco.com

if you have issues registering, please email above and we will send you an invoice directly.

Email *

First Name *

Last Name *

Phone Number *

Name of Practice/Employment

Practice Location (please note if virtual only)

Which Mental Health License do you hold? (please check all that apply)

LMHC

LCSW

LMFT

LCAT

MSW

MHC-LP

PMHNP

Mental Health Counselor graduate student (counseling intern)

Social Work graduate student (social work intern)

Other:

What setting do you work in? (please check all that apply)

School

Outpatient Community Mental Health

In-patient Facility

Private Practice

Psychiatric Unit in Hospital

Other:

What population do you work with?

What is your area of focus?

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