"Authenticity is a collection of choices that we have to make every day.
It's about the choice to show up and be real.
The choice to be honest. The choice to let our true selves be seen."
Please read and check each box, electronically sign and date below.
I understand that it is my responsibility to keep all scheduled appointments for myself or my family. Any requests for rescheduling or cancelling an appointment requires a minimum of 24 hours notice for current patients and 48 hours notice for new patients. Notifications less than this will result in a $25 charge. It is best to Call the office and leave your message to assure any appointment matters are handled promptly. We request you not to email your notification.
I understand that three missed appointments that are not rescheduled, will result in termination from the practice.
I understand that payment is expected at the time of service for any copay or co-insurance or in full if no insurance is billed. Should there be any dispute with my insurance for denial of services, for whatever reason, it is my duty to resolve and be responsible for whatever amount remains.
I understand that I am responsible to keep any personal information such as change of address, email, phone numbers, insurance coverage, and any credit card information kept on file, up to date.
I understand that psychotherapy services provided by Marilyn Pearlman are for myself or for my family's personal purposes. I will not request or utilize her services to contribute to any legal matters, nor for supporting an application for Social Security disability or Workman’s Compensation.
By clicking this box and by entering my name and today's date in the following fields, I am electronically signing and agreeing to the above Billing Policy.
Client Consent allows us to obtain from or send records to designated providers and schools, if necessary.
I give Marilyn Pearlman, LCSW my permission to communicate and/or share information on my behalf, or for my child, with the following professional providers or schools. I may either initiate this request for collaboration, or I will give approval for the consultation should it be coming from one of my providers or schools. I give my permission to the following providers/schools:
Patient or Patient's Representative:
By clicking this box and entering my name below, I authorize the use of this electronic form for the disclosure of the information described above from the listed people and places.
Click the following button to submit your information and go to the Insurance Card and Drivers License upload window.
If an Error message occurs, scroll through this form, please complete the red bordered fields, and resubmit.