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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 (830) 515-4343 x103. 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.).

Interested In
Check all that apply
Required
Potential Client Information
Name:
First and Last Name
Your answer
Gender:
Date of Birth
MM
/
DD
/
YYYY
Client Address
Your answer
Client City
Your answer
Grade
Placed With:
Social Security Number
Your answer
Medicaid Number
Your answer
Primary Diagnosis (DSM-V)
Your answer
Name of Diagnosing Professional
Your answer
Diagnosis Date
MM
/
DD
/
YYYY
Reason for Referral / Presenting Problems
Select all that apply
Required
What is your relationship of the person making this referral to the potential client?
Select one
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This form was created inside of Pathways Youth & Family Services. Report Abuse - Terms of Service - Additional Terms