Forms

PLEASE CONTACT DR GEISER DIRECTLY BEFORE SENDING ANY OF THE FORMS BELOW.  The Guarantee of Payment and Credit Card Payment forms will be used only If you plan to use your insurance coverage (currently only new patients with Medicare or Tricare are accepted).  If you schedule and meet via the SessionSync portal, consent forms or other authorization forms will be provided via that site. 

You may send the forms below in 3 possible ways.  First, the most secure is through the TherapyAppointment electronic record portal.  After contacting Dr. Geiser and providing some basic information and scheduling your appointment, he will give a secure link through which the forms can be sent.  The second option is printing the forms, completing them, and sending them as email attachments prior to your first session with Dr. Geiser.  Third, you may submit them via text message photos (less secure) to his mobile number. 

If you have questions about any of the forms, please contact Dr. Geiser at 239-822-2915 via audio or text.  Be sure to give your name and leave a voicemail message, if he is unable to take your call.

Psychological Services Consent to Treatment

Telepsych-Consent.10.2.2023.pdf

Guarantee of Payment Consent

Confidentiality Statement  (See associated HIPAA Florida Privacy Statement)

Credit Card Payment Form  (Please call office if questions)

If you would like Dr. Geiser to send any information to your referring provider,  psychiatrist, or primary physician, complete and sign the form below.  Please check off specific information that you would like to have released by Dr. Geiser or obtained by him from providers or other entities.  If you wish to release information from Dr. Geiser and allow him to obtain information from the designated person or entity, then circle both "release" and "obtain" when you complete the form.

Authorization to Release Information

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