Independent Living Program For Young Adults with Learning Disabilities

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

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

Health Insurance Information

Education

Vocational Rehabilitation or Vocational Training Programs

Are you a California Resident?

Work Experience
Do you have work experience (Include volunteer jobs)

Other Information

Referral Source: Please indicate where or from whom you learned about Independence Center