Continual Care

Clinic Services

Please complete the referral form in its entirety and ensure that the information you have entered is accurate. Any additional information that you would like to share can be typed into the "Interests" box. Please contact maggie.mahoney@mozaic.org if you have questions or concerns.

Request Information

The following documents must be attached:

1. Life Plan (required)
2. Psychological Evaluation
3. OPWDD Eligibility Letter
4. Other information to include: copies of all insurance cards (front and back), Social Security card, photo ID, legal guardianship court documents, IG's, BSP's, Treatment Plans, medical information, etc.

Submitter Information

Enter your contact information so that we can contact you if we have any questions.

Name:	Preferred Name:
Email:	Phone:

Address 1:	Address 2:
City:	State: --Choose One-- --Choose One-- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	County: --Choose One-- --Choose One--	ZIP code:

Request Programs

Select the programs the applicant is considering.

Occupational Therapy	Physical Therapy	Psychiatry
Psychology	Rehabilitation Counseling	Social Work
Speech Language Therapy

Applicant Contact Information

Enter contact information for the primary applicant

Email:

Phone:

Alternate Phone:

Address 1:	Address 2:
City:	State: --Choose One-- --Choose One-- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	County: --Choose One-- --Choose One--	ZIP code:

Applicant Name

Identify the primary applicant

SSN:

Salutation:

None

First:*

Middle:

Last:*

Suffix:

Date of Birth:

Open the calendar popup.

Demographics

Enter demographics for the primary applicant

Gender Identity:

--Select One--

Race:

--Select One--

Ehnicity:

--Select One--

Sex Assigned At Birth:

--Select One--

Living Arrangements:

--Select One--

Household Type:

--Select One--

Marital Status:

--Select One--

Primary Language:
English Choose Clear

Insurance

Click the Plus icon to add items and the Minus icon to remove items

Company

Policy

Type

Physician Information

Enter information about the applicant's primary care physician. If none, then leave blank.

Name:
Email:	Phone:

Organization Name:

Address 1:	Address 2:
City:	State: --Choose One-- --Choose One-- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	County: --Choose One-- --Choose One--	ZIP code:

Care Manager Information

Enter information about the applicant Care Manager. If none, then leave blank.

Name:
Email:	Phone:

Address 1:	Address 2:
City:	State: --Choose One-- --Choose One-- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	County: --Choose One-- --Choose One--	ZIP code:

Guardian Information

Enter information about the applicant guardian. If none, then leave blank.

Name:
Email:	Phone:

Address 1:	Address 2:
City:	State: --Choose One-- --Choose One-- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	County: --Choose One-- --Choose One--	ZIP code:

Medical Information

Enter medical information about the applicant in the section labeled [Other].

Disability:

--Select One--

Permanence:

--Select One--

Age at Diagnosis:

Year of First Diagnosis:

ISPM Score:

Disability flags:
Special Needs

Other:

Interests/Other

Describe the client's interests, i.e. what is prompting submitting this application.

Files

Click the corresponding button to upload your file.

OPWDD Eligibility Letter

Pending

Psychological Evaluation

Pending

Lifeplan

Pending

Copies of all insurance cards (front and back)

Pending

Social Security card

Pending

Photo ID

Pending

Legal guardianship court documents

Pending

IGs

Pending

BSPs

Pending

Treatment Plans

Pending

Medical Information

Pending

Other

Pending

Other Information

Enter as much information below as possible. Fields that say 'required' or have a blue bar are required.

TABS ID

Tracking and Billing System Identification Number assigned when applying for OPWDD services (Text) (Required)