Client Information

Please complete the following three pages in their entirety. 

Primary Client

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Marital Status:

Family Information

Provider Information

Insurance Information

Assignment and Release:

I certify that the insurance policy information provided for myself and any of my family members is current and correct. I approve the assignment of benefits to the named provider, Marilyn Pearlman, LCSW. I understand that I am fully responsible for all charges for services rendered, regardless of whether my insurance ultimately pays the claim. I authorize the provider to release all necessary information in order to secure payment for services, and I approve my signature below on all insurance submissions. I assume responsibility to procure any and all forms in a timely manner if utilizing EAP benefits provided by my insurance coverage.

 I understand and agree to the above Assignment and Release statement.

Couples

Check boxes below that apply: 

Anxiety

Dementia

LBGTQ Issues

Depression

Work/Retirement Issues

Divorce/Separation

Traumatic Brain Injury

Grief and Loss

Attention Deficit Disorder

Addictions

Life Trauma

Family/Parenting

Bipolar

SUBMIT FORM

Click the following button to submit your information.
You will be directed to the Consent and Billing Policy page.  

If an Error message occurs, scroll through this form, please complete the red bordered fields, and resubmit.