Mosaic Counseling & Wellness - Psychiatry/Medication New Patient Inquiry

Psychiatry/Medication New Patient 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

Are you currently on medications? *

No Yes

Please note we will need a list of current meds prior to the first appointment

Patient First name *

Patient Last name *

Patient email *

Patient Phone *

Patient DOB *

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

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

Brief History

It is ideal that we receive as much information up front as possible in order to place you with the most appropriate provider, however, if you are not able to fill out all questions this will not prevent you from getting an appointment. Some questions you can answer n/a for**

Please provide a brief history of current concern

History of psychiatric care *Please include outpatient care as well as listing any inpatient, or partial hospitalization history

Current substance use (including alcohol)?

Past history of substance use or treatment for substance use disorder?

Previous medications

Current medications

Previous Diagnosis

Current Diagnosis

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.

Any health issues past or present we should be aware of?