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BART ROSS, Ph.D., PSYCHOLOGIST 

Licensed Clinical Psychologist

Certified EMDR Therapist

Trained Divorce Mediator

Over 30 Years in Clinical Practice

323.791.1808

INDIVIDUAL

RELATIONSHIP

GROUP

DIVORCE MEDIATION

NEW PATIENT INFORMATION

INSURANCE VERIFICATION

  1. Name:

  2. Address:

  3. Phone Number:

  4. Date of Birth:

  5. Gender:

  6. Picture of insurance card (front and back)

  7. Picture of drivers license

PLEASE FORWARD THE INFORMATION TO MY EMAIL ADDRESS: [email protected]