Mosaic Counseling & Wellness - New Patient Inquiry

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New Client Inquiry
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New Client Inquiry

Psychiatry/Medication New Client Inquiry

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New Client Inquiry

Please fill in the details below to schedule with one of our clinicians

Are you seeking... *

Is this for you or a loved one? *

myself a loved one

your First name *

your Last name *

Your Email *

Your Phone *

Client First name *

Client Last name *

Client email *

Client Phone *

Client DOB *

Client Address *

Client Address 2

Client City *

Client State *

Client Zip *

Preferred Method of Contact

Phone Email

Get Started

Submit Test

Quick Insurance Check

Let's learn if Mosaic is in network with your insurance

Please select your insurance provider *

Aetna PPo

BCBS PPO

Cigna PPO

Medicare

United healthcare ppo

self-pay

Please provide the information below so we may assist in a courtesy verification of benefits.

Member ID

Group Number

Customer Service Number

Primary Card Holder Name

Primary Card Holder DOB

Next Step

Let's learn where/when you are seeking care

Please fill in your preferences below and one of our team members will be in touch with you soon

Your preferred Mosaic Location *

your preferred time of day *

Your Preferred Day(s) *

Mon

Tues

Wed

Thur

Fri

Sat

Sun

Next Step

Lastly, what brings you to Mosaic?

Please share why you are seeking care so we may best understand your needs

questions?

Thank you! Your submission has been received!

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Community Partners

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Get in touch

386 N. York Road, Suite 204 & Suite 202, Elmhurst, IL, 60126

460 N Main Street, Unit 205, Glen Ellyn, IL, 60137

119 East Ogden Ave, Suite 130, Hinsdale, IL, 60521

215 Harrison Street, Oak Park, IL, 60304

Orland Park, IL

9501 W. 144th Place, Suite 304, Orland Park, IL, 60462

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