Please read and check each box, electronically sign and date below.
I (client/guarantor) understand that:
I am responsible to keep all scheduled appointments for self or family. Any requests for rescheduling or canceling an appointment requires a minimum of 24 hours' notice for current patients and 48 hours' notice for new patients. Notifications less than 24 hours this will result in a $35 fee. I understand that I must call the office and not leave any requests via email.
Two no show appointments will result in termination from the practice. A $35 fee will be assessed for each missed appointment.
Payment in full is expected at the time of service for any copay or co-insurance or if no insurance. I am responsible for any disputes with my insurance and for any remaining balances.
I am responsible for keeping personal information updated, such as address, email, phone numbers, insurance coverage, and credit card information on file.
Services provided by Marilyn Pearlman may not be used for legal matters, nor to support an application for Social Security benefits, disability or worker’s compensation.
I understand and agree 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.
psychotherapy ADHD ADD Marriage Counseling Family Therapy Couple Therapy Trauma Stress Work LCSW Social Worker Phone Counseling PTSD Anxiety Depression Grief Dementia Addictions Bipolar Coaching Brain Mindfulness
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