Enroll at Bright Mosaic!

Before You Begin

Insurance Networks: We’re NOT in-network with Tri-Care or Medicaid at this time.

Speech & Occupational Therapy Requirements: In order to qualify for Speech & Occupational Therapy services, a client must also be enrolled in Bright Mosaic’s ABA Program.

Step 1 of 10

Child's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Parent Contact Info
Name of Parent or Guardian*
First Last
Phone*
Email*
Name of other Parent or Guardian
First Last
Phone
Email

Vaccine Requirements

Bright Mosaic requires that clients meet the Texas Minimum State Vaccine Requirements for Child-Care and Pre-K Facilities

The following link will open a separate tab. Please use the following link to verify that your child meets the requirements for services.
https://www.dshs.texas.gov/immunize/school/child-care-requirements.aspx
Vaccine Verification*
I've verified that my child meets the "Texas Minimum State Vaccine Requirements for Child-Care Facilities"

Sibling Info
Siblings*
Does the child have siblings?
- Yes
- No
Household*
Do they live in the home?
- Yes
- No
Age*
List the ages of siblings (separated by commas)

Child's Communication*
Check all that apply.
- Does not speak
- Speaks in 1-2 word phrases
- Speaks in longer phrases
- Hard to understand
- Speaks age-appropriately
Communication Description*
Describe how your child communicates wants and needs.
Communication Concerns*
Describe your communication concerns.

Child's Social Interaction*
Check all that apply.
- Seems uninterested in others
- Watches others, but limited interactions
- Initiates interactions, but does not seem to know how to interact like others his/her age
Interaction Description*
Describe how your child interacts with peers and adults.
Interaction Concerns*
Describe any concerns you have about your child’s social interactions.

Challenging Behaviors*
Check all that apply.
- Aggression
- Property destruction
- Non-compliance (e.g. saying no ignoring requests)
- Leaving a designated area
- Tantrums (e.g. screaming, crying dropping to the floor)
Behavior Concerns*
Describe any concerns you have about your child’s challenging behavior.

Preferred Items/Activities*
Please list preferred items/activities for your child.
Aversive Items/Activities*
Please list any items/activities that are highly aversive to your child.
Main Concerns*
What are your main concerns and/or treatment goals?

Payment Information*
Private Pay
Insurance
Insurance Information
Insurance Company*
Blue Cross Blue Shield State*
Phone*
Fax
Policyholder Name*
First Last
Policyholder Date of Birth*
MM slash DD slash YYYY

Policyholder Gender*

Male

Female
Policyholder SS#*
This is required for Tricare.

Policy ID*
Policy #

Group*

Enroll at Bright Mosaic!

Step 1 of 10

Parent Contact Info

Vaccine Requirements

Bright Mosaic requires that clients meet the Texas Minimum State Vaccine Requirements for Child-Care and Pre-K Facilities

The following link will open a separate tab. Please use the following link to verify that your child meets the requirements for services.

Sibling Info

Occupational Therapy

Physical Therapy

Speech Therapy

Early Childhood Intervention

Special Education Services in a Public or Private School

Counseling or Psychiatric Services

Upload Documents

Insurance Information

Ready to take the next step?

Enroll at Bright Mosaic!

Step 1 of 10

Parent Contact Info

Vaccine Requirements

Bright Mosaic requires that clients meet the Texas Minimum State Vaccine Requirements for Child-Care and Pre-K Facilities

The following link will open a separate tab. Please use the following link to verify that your child meets the requirements for services.

Sibling Info

Occupational Therapy

Physical Therapy

Speech Therapy

Early Childhood Intervention

Special Education Services in a Public or Private School

Counseling or Psychiatric Services

Upload Documents

Insurance Information

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Ready to take the next step?