Contact Your Name * Full Name Child Name If you are requesting therapy for a child, what is their name? Email Address * Email Address Phone Number * Phone Number Checkbox I agree to receive text communications from you. Line By entering your phone number, you agree to receive informational SMS messages (appointment reminders, account notifications, etc.) from us. Message frequency varries. Message and data rates may apply. For help, reply HELP or email us at info@mosaiccw.com. You may opt out at any time by replying STOP. Visit https://mosaic.care/privacy-policy for more information. Insurance * What kind of insurance do you have? Availability * What is your preferred appointment day and time? Interest * What are you interested in? Therapy for myself Therapy for my child Family therapy Couples therapy Art therapy Other Why? * Please, briefly, share why you would like therapy. Anything else you want to share? Anything else you want to share? Thank you!
