Kevin P. Geis, PhD, LLC
Maryland Licensed Psychologist
Child &
Adolescent
Specialty
Voice & Text: (717) 377-2192
I PREFER TEXTING / EMAILING when getting started.
Once underway and Protected Health Information needs to be exchanged we'll use Email and Google Meets exclusively for End-to-End Encryption privacy .
NOTICE: The Preserve Telehealth Access Act of 2023 (Senate Bill 534) permits TeleHealth in the home until June 30, 2025. In-office appointments are also available.
*New In-Office Location*
837 Spruce St.
Head Start of Washington, Co.
(Sgt. Shriver Center)
*Use This Address for All Mailing *
111 S. Main St.
Mont Alto, PA 17237
If Legal Custody or Guardianship has been determined by court order,
I am required by law to follow that document and therefore
MUST HAVE A COPY before the first Session can begin.
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NOTE: While TeleHealth continues these forms below can be sent as attachments using email. There are two options to complete and send these forms.
1. All Digital Technique: Click on the link below. Once file opens, select the "Texting" Tool located in the top right of the file's Menu Bar to complete the form. "Save" the file, then send the saved file as an attachment
(send as an email attachment).
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2. Paper Technique: Click on the link below. Print the form to paper. Complete form and take cellphone photo of completed form. (Send picture as an email attachment).
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All these forms below are available at the office for your completion; however, I encourage you to consider completing them at home and bringing them along to allot more time discussing your child.
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1.
"Notice of Privacy Practices"
(Review)
2.
"CMS 1500" Medical Claims Form.
Fill in Boxes 1 through 13.
Along with the additional information need for the Chart.
(Complete, Sign, & Send)
3.
"Informed Consent for TelePsychology".
(Review)
4.
"Consolidated Signature Form".
(Sign & Send)
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Additional Forms
(if requested)
A. Consent to Release Information:
B. Visiting your Child in their Washington County Public School:
(2024-25 Academic Year)
