Contact Us for Mental Health Support (833) 260-9811 office@mosaic-clinic.com I am a new client seeking care please complete this form for the fastest possible match with your new therapist. "*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.Full Name (first and last name)*Date of birth Please let us know your date of birth so we can create a "Therapy Portal " account for you to start the registration process.Email* I want therapy because ...let us know a bit about why you are seeking care at this time. Days Times I would like to have appointmentsDay Time AMDay Time LunchDay Time AfternonEvening (after 6pm)Saturday AMSunday AMPlease let us know when you are available for care. please select all that apply Insurance Card Uploadplease upload a copy of your insurance card/ or EAP authorization Drop files here or Select files Max. file size: 1 GB, Max. files: 3. Phone*just in case, please let us know how to contact you if email fails.
