New Client Inquiry | Mosaic Counseling & Wellness

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 *

Preferred Method of Contact *

Phone

How Did You Hear About Us?

Get Started

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 *

Email *

Address (If different)

Family Member *

Name *

DOB *

Phone *

Email *

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.