Expedited Appointment Request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for reaching out. We’re glad you’re here.

Where things stand (updated October 2026)

• Adults: Our therapists are full, but we are adding adults to our waiting list.

• Teens and their families: We have a few openings for teens. Our therapist works closely with parents as part of treatment.

• Children (under 13): We are adding children to our waiting list.

• Parents: We have space in our Parent ARFID Support Group and FBT Parent Support Group. They’re a great place to start. Email hello@edtla.com to join.

To get matched faster

1. Answer every question you can. Parents, please fill this out for your child.

2. Email a photo of the front and back of your insurance card(s) to hello@edtla.com.

This form is secure and HIPAA-compliant.

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: *

YYYY

Phone Number: *

State: *

California

New York

South Carolina

Indiana

Oregon

Florida

Other:

City: *

Requested Clinician

Appointment Preference *

Virtual (most likely to have faster openings)

In person

Whichever is available first

Other:

Preferred Appointment Day and/or Time

Weekdays Morning

Weekdays Afternoon

Other:

Clear selection

Insurance Type
*Please indicate all health insurance plans *

Anthem

Anthem Medi-Cal

Anthem UC Ship (requires a referral from student health services)

Aetna/Meritain

Blue Shield of California

Blue Shield of California Wellfleet

Lyra

Kaiser (requires a referral from a case manager)

Carelon (formerly Beacon Partnership)

Medicare

Insurance not listed, but was told EDTLA is in network with my plan.

Use my Out of Network Benefits

Pay Out of Pocket to See Therapist

Pay Out of Pocket to Psychological Extern (Low Fee Option)

Other:

Required

Please Select Which Answer Best Describes Your Insurance Coverage: *

I am only insured by one insurance plan.

I have more than one health insurance plan.

I am unsure if I am insured.

I am uninsured.

I intend to be a private pay patient.

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.

Eating Disorder - Adult

Eating Disorder - Child

Eating Related Phobia

Body Image Concerns

Anxiety

Depression

Other:

Required

If you are seeking help for an eating disorder, please specify which: *

Avoidant Restrictive Food Intake Disorder (ARFID)

Atypical Anorexia

Anorexia

Binge Eating Disorder

Bulimia

Disordered Eating

Emetophobia

OSFED

I am not seeking help for an eating disorder.

Other:

Required

Are you currently seeing another therapist or mental health professional?

Yes

Other:

Group Therapy & Support Groups

I have interest in joining the Young Adults Process Group.

I have interest in joining the ARFID Parent support group.

I have interest in joining the FBT Parent support group.

Clear form

Never submit passwords through Google Forms.

This form was created inside of Eating Disorder Therapy LA.

Does this form look suspicious? Report

Forms