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
or call (844) 591-9055. Thank you!
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.).
First and Last Name
Date of Birth
Social Security Number
Type of Insurance
Beacon Health Strategies
Molina Health Care
North Texas Behavioral Health Authority
Insurance ID Number
What is the relationship of the person making this referral?
Other Family Member
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