Referral Form

Please enter your information using this HIPAA-encrypted secure form.

Once you submit this form, our team will contact you within 48 business hours to discuss next steps.

We always welcome your communication, by any method you choose:

1. Use this HIPAA-encrypted form (below) as often as needed

2. Call us at (310) 825-2305 option 1.

3. Email us at ucla@psychclinic.hush.com

4. Fax (HIPAA secure): (310) 825-6632

We look forward to working with you!