Contact Us

Name

First Name

Last Name

Phone Number

Email Address

How Did You Hear About Us?

Referral Source (if referred by a clinician)

Please provide the name of the clinician who referred you to TLA Therapy

Reason for Reaching Out

Office Location Preference

Scheduling Preferences/Limitations

Please indicate scheduling preferences and / or limitations for therapy (e.g., only available from 12-3pm on Monday-Friday)

Insurance

Do you have UC SHIP insurance (please note, we don't accept any other private insurance at this time; however, we can provide a superbill to get reimbursed by your insurance if you're eligible for out-of-network benefits)?

Yes

No

Additional Comments

Is there anything else you'd like to share (e.g., why you're interested in therapy, your goals for therapy, etc.)?

OFFICE LOCATIONS

Culver City

9696 Culver Blvd, Suite 303, Culver City, CA 90232

Encino

16530 Ventura Blvd #400, Encino, CA 91436

Redondo beach

2512 Artesia Boulevard, Suite 305C, Redondo Beach, CA 90278

Torrance

24445 Hawthorne Blvd, Suite 211, Torrance, CA 90505

West LA

1849 Sawtelle Blvd, Suite 610, Los Angeles, CA 90025