Request for Care | JourneyCare

At JourneyCare, we are committed to providing care and support for our patients and families when they need us most. We encourage you to contact our team via phone for immediate assistance — 24 hours a day, seven days a week, at 844-6-JOURNEY (844-656-8763). Or you may complete this brief form so the appropriate JourneyCare team member can follow up with you as soon as possible.

Service(s) Requested*
Was your loved one on JourneyCare services?
- Yes
- No
Please provide the patient's name
Patient's Name*
First Last
Location of Patient's Residence*
Relationship to Patient
Diagnosis*
Primary Care Doctor (if available)
First Last
Your Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Email
Please provide any additional information regarding why you are reaching out for grief support? (300 character limit)
Email
This field is for validation purposes and should be left unchanged.