New Client Inquiry

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

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

How Did You Hear About Us?

Let's learn why you are seeking care

Please fill in some extra details and one of our team members will be in touch with you soon

What Services Are You Seeking?

Partner Information

Name

DOB

Phone

Address (If different)

Family Member

Name

DOB

Phone

Address (If different)

Family Member 2 optional

Name

DOB

Phone

Address (If different)

Family Member 3 optional

Name

DOB

Phone

Address (If different)

Current Medications (Including Dosage)

Previous medications (Including Dosage)

Current Diagnosis

Previous Diagnosis

Current substance use (Including Alcohol)?

History Of Substance Abuse And Treatment?

Any health issues we should be aware of?

Preferred Pharmacy

Please provide a brief history of current concern

Do you have a recent (within 3 years) neuropsych evaluation?

No Yes

If so, please send it to info@mosaiccare.com before your first appointment, or upload it to your Simple Practice portal when you are scheduled. Having this evaluation prior to your first appointment will make the appointment time more productive and help get to your treatment goals faster.

New Client Inquiry

Insurance & Availability Check

Let's learn why you are seeking care