MOSAIC REFERRAL FORM
Please complete and submit the form below and a Qualified Mental Health Professional will contact you to initiate. If you have any questions regarding Mosaic's services or any of the eligibility criteria listed below, please email referrals@mosaic-consult.com or call (844) 591-9055. Thank you!
Eligibility Criteria
An individual is eligible for Mosaic services if the individual is:
· age 3 and older;
· a resident of the State of Texas;
· enrolled in a managed care Medicaid program; and
· a child or adolescent with a serious emotional disturbance with a DSM-V primary diagnosis or has experienced a severe traumatic event (e.g. abuse/neglect, home removal, etc.).

Client Information
Name: *
First and Last Name
Your answer
Gender: *
Date of Birth *
MM
/
DD
/
YYYY
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Social Security Number
Your answer
Type of Insurance *
Insurance ID Number
Your answer
What is the relationship of the person making this referral?
Select one *
Next
Never submit passwords through Google Forms.
This form was created inside of Pathways Youth & Family Services. Report Abuse - Terms of Service - Additional Terms