Get in Touch with Journey

Submit Your Individual Application Information

Please note, we are experiencing a large number of referrals. Thank you for your patience!

Name(Required)

First Last

Preferred Name

Your Pronoun(s)

Date of Birth(Required)

Primary Insurance Provider(Required)

Please note that our clinicians who accept UPMC for You (and all Medicaid plans), UPMC for Life (and all Medicare plans), and UPMC commercial plans are unable to see clients for two months. We understand how difficult this is for you. Our office manager will attempt to assist you with finding another provider with availability in your area if you are unable to wait.

Insurance ID#(Required)

Who provides this insurance?(Required)

Insurance Policy Holder(Required)

If you have secondary insurance please list it here.

Home Phone

Cell Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Preferred Method of Contact:(Required)

Do you have any ADA needs?(Required)

Please describe accessibility/mobility requirements(Required)

Best Days/Times for Appointments?(Required)

Is there a therapist you would like to work with?(Required)

Needs/Goals for Therapy:(Required)

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Get in Touch with Journey

Submit Your Individual Application Information

AVAILABLE AT 9AM TO 6PM

(833)4UR-JRNY / (833)487-5769

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