Dr. Ryan Kitts Schallon | SimplePractice

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Pronouns

Billing & Payment

Insurance details

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Client Preferences

Preferred appointment times

Morning Afternoon Evening

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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Do you consent to the use of AI in the delivery of your care?

I would like to request your consent to use AI tools (such as using AI to generate an intake summary and other insurance documentation) to help support your care and free up my time to better commit to your clinical care. Your information is protected under HIPAA and anything generated by AI is always reviewed by me. Sessions are recorded and live transcribed and then the audio and transcription are deleted upon completion and approvalof the note. Your data will not be used for training AI models. AI does not make decisions about your care. You can withdraw this consent at any time by contacting me. I welcome any conversation to help clarify any questions and/or concerns.

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Reason for care

What is the reason you're coming into treatment?

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Why now? Has anything recently occurred that motivated you?

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Have you been in treatment before? If so, when and for how long?

If you have had treatment before, what was helpful and what wasn't?

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What are you hoping to derive from our treatment together?

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.