Get in Touch with Journey 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 NameYour Pronoun(s)Email(Required) Cell Phone(Required)Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Insurance(Required)Insurance ID #(Required)Who Provides the Insurance?(Required)Secondary Insurance?(Required)NoYesSecondary Insurance ProviderSecondary Insurance ID #Do you have any accessibility/mobility issues?(Required)YesNoAddress(Required) Street Address City ZIP Code Preferred Method of Contact(Required)Phone CallEmailTextGroup Therapies:(Required) Art Therapy | Mondays | 5:00pm-7:00pm Journey Through The Shadows | Thursdays | 5:30pm - 7:00pm Goals for Therapy:Are you a current client of Journey to a Trauma Informed Life?(Required)YesNo AVAILABLE AT 9AM TO 6PM (833)4UR-JRNY / (833)487-5769 Send us an Email