Admissions

Please fill out the following information to start the admissions process.

If you have any questions, please call 310.205.6991.

ADMISSIONS

If you have insurance, please enter your information below to verify your benefits and determine any out-of-pocket costs. ALL INFORMATION YOU SUBMIT IS CONFIDENTIAL.

Contact Name *
Contact Name
Patient's Name (If different than above)
Patient's Name (If different than above)
Patient's Date of Birth *
Patient's Date of Birth
Subscriber's Name (if different than the patient)
Subscriber's Name (if different than the patient)
Subscriber's Date of Birth
Subscriber's Date of Birth
Address *
Address
Phone *
Phone
Insurance Phone Number (Located on card)
Insurance Phone Number (Located on card)
Insurance Behavioral Health Department (Located on card)
Insurance Behavioral Health Department (Located on card)