Insurance & Payment Information

Please provide your insurance information or select self-pay. This is the final form in the new client paperwork.

Payment Method

Insurance

Bill my insurance provider

Self-Pay

$125 per session

Insurance Information

Insurance Company *

Member ID *

Group Number

Is the policyholder someone other than you?

No, I am the policyholder Yes, someone else

Authorization

I authorize Journey Ahead Resources, LLC to release any information necessary to process insurance claims on my behalf. I understand that I am financially responsible for any charges not covered by my insurance. I understand that I am responsible for payment of services rendered, including any copays, deductibles, or amounts not covered by insurance.

Electronic Signature

Full Legal Name *

Today's Date *

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