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!
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 or has insurance with one of our contracted insurance companies; 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
Client Primary Language *
Gender: *
Date of Birth *
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Social Security Number
Your answer
Type of Insurance *
Insurance ID Number
Your answer
Service Location Preference (if available)
What is the relationship of the person making this referral?
Select one *
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This form was created inside of Pathways Youth & Family Services. Report Abuse - Terms of Service