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Submit Your Group Therapy 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)

Email(Required)

Cell Phone(Required)

Date of Birth(Required)

Primary Insurance(Required)

Insurance ID #(Required)

Who Provides the Insurance?(Required)

Secondary Insurance?(Required)

Secondary Insurance Provider

Secondary Insurance ID #

Do you have any accessibility/mobility issues?(Required)

Address(Required)

Street Address City ZIP Code

Preferred Method of Contact(Required)

Group Therapies:(Required)

Art Therapy | Mondays | 5:00pm-7:00pm

Journey Through The Shadows | Thursdays | 5:30pm - 7pm

What’s This About? | Youth Art Therapy | Tuesdays | 4:00pm - 6:00pm

Goals for Therapy:

Are you a current client of Journey to a Trauma Informed Life?(Required)