Application

Independence Center

36040 South Sepulveda Blvd., Suite 102, Los Angeles, California 90034
Phone (310) 202-7102
Fax (310) 202-7180

PLEASE FILL OUT ALL FIELDS

Current Psychiatrist, Therapist or Social Worker

Dates of Treatment

Please list all medical facilities, mental health agencies and psychiatrists, psychologists, social workers or other therapists with whom you have had contact within the past 5 years, and to whom we can send for records.

Health Insurance Information

Education

Vocational Rehabilitation or Vocational Training Programs

California Residents Only

Work Experience

Other Information