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Intake Form

Please Fill Out This Form Prior to Consultation (All information used is kept confidential in compliance with HIPPA and is discarded after consultation)

Birthday
Month
Day
Year
What state are you in?
Are you seeking therapy to support any of the following:
Which service(s) / type of therapy are you interested in?
Do you have Maryland Medicaid?
Yes
No
Other
What are you time/day preferences for appointments ?
CONTACT US

admin@kylacaretherapy.com

Telehealth: Serving Maryland,
Washington, D.C., Idaho,
and Washington State

Clients in all other states may attend groups and receive support planning services.

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©2025 by Kyla Care

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