Expedited Appointment Request

PLEASE READ CAREFULLY BEFORE COMPLETING OUR GOOGLE FORM.

If you are seeking treatment on behalf of a child under 18, please complete all info (or as much as possible) on their behalf to the best of your ability.

We are accepting new clients, and have immediate openings for adults with our staff therapists!

We have a waiting list for children and teens.

We also have space in our Parent ARFID Support Group and our FBT Parent Support Group. If applicable, you are strongly encouraged to start with whichever group is most applicable to learn more about our treatment approaches for children and teens.

If you have interest in joining one of our groups, please email us at hello@EDTLA.com.

We receive a high volume of inquiries to be seen at EDTLA. Competing this form in its entirety along with emailing us a photo of the front and back of your insurance card(s) to hello@edtla.com will expedite your connection to a therapist at our practice.

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Email *
Legal Name:
(Please list the name of the potential patient.) *
Preferred Name:
Pronouns:
Name of Person Completing Form & Relationship to Patient
Patient Date of Birth: *
MM
/
DD
/
YYYY
Phone Number: *
State: *
City:  *
Requested Clinician
Appointment Preference *
Preferred Appointment Day and/or Time
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Insurance Type
*Please indicate all health insurance plans *
Required
Please Select Which Answer Best Describes Your Insurance Coverage: *
Primary Insurance ID Number
Please also email a copy of the front and back of your insurance card(s) to hello@edtla.com.
Secondary Insurance ID Number (if applicable)
Please also email a copy of the front and back of your insurance card(s) to hello@edtla.com.
What Are You Primarily Seeking Help For?

Please select all that apply. If you are seeking help for one or more mental health diagnosis not listed, please list them in the "other" section.
 *
Required
If you are seeking help for an eating disorder, please specify which: *
Required

Are you currently seeing another therapist or mental health professional?

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Group Therapy & Support Groups
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