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

Date

Name

First and Last

Home Address

City

Zip

Email Address

With whom are you currently living?

Date of birth (type the year in after selecting month and day)

Social Security Number

xxx-xx-xxxx

Sex

Male
Female

Height

Weight

Name of Parent/Guardian

Guardian address

City

Zip

Phone (Home)

(xxx) xxx-xxxx

Office Phone

(xxx) xxx-xxxx

Check all that apply

I've had a major illness or hospitalization in the last 5 years
I have allergies
I currently take medications

Nature and duration of major illnesses

Current Diagnosis

List all allergies

Current Diagnosis

List all current medications

Current Diagnosis

Current Psychiatrist, Therapist or Social Worker

Name

Address

City

Zip

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.

Name

address

City

zip

Family Physician Name

Physician phone

(xxx) xxx-xxxx

Physician address

City

zip

Health Insurance

Health Insurance Information

Company Name

Policy Number

Education

School Name

Dates attended

Address

City

Zip

Vocational Rehabilitation or Vocational Training Programs

Have you attended one of these programs?

Name of Program

Dates attended

Address

City

Zip

Reason for leaving

California Residents Only

Are you a California Resident?

Are you now, or have you been a Regional Center Client?

Name of Regional Center

Dates you were a client

Work Experience

Do you have work experience (Include volunteer jobs)

Name of Employer

Address of employer

Reason for leaving

Dates you worked

Nature of job

Salary

Amount per hour

Have you been employed by anyone else?

Name of employer

Address of employer

Reason for leaving

Dates you worked

Nature of job

Salary

Other Information

Hobbies and Interests

Referral Source

Please indicate where or from whom you learned about Independence Center

Independence Center

PLEASE FILL OUT ALL FIELDS

Current Psychiatrist, Therapist or Social Worker

Dates of Treatment

Health Insurance Information

Education

Vocational Rehabilitation or Vocational Training Programs

California Residents Only

Work Experience

Other Information