Michael Braun

"You create a good future
by creating a good present."

Eckhart Tolle

Client Information Form

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.

By clicking this box and entering my name and today's date in the following fields, I am electronically signing and agreeing to the above Assignment and Release statement.

Reasons for Seeking Service

Anxiety

Family Problems

Work Related Issues

Bipolar

Grief and Loss

Couple Problems

LBGTQ Issues

Attention Deficit Disorder

Depression

Divorce/Separation

Life Trauma

Addictions

Domestic Violence

Traumatic Brain Injury

Other (Please Explain)

Clicking the following button opens an email window to notify the office that you've started the necessary forms.
Enter your name, where indicated, on the email subject line and send.
You will be transferred to the Client Consent & Billing Policy forms to complete. 

Thank you for your cooperation.

Office Location: 3293 Fruitville Road, Suite 104, Sarasota, FL 34237