Client Forms

General Intake Form
Areas of tension (check all that apply)

MEDICAL HISTORY: Indicate below any significant medical conditions

I understand that the services provided are not a replacement for medical or psychological care and that any information provided is not prescriptive or diagnostic in nature and is for educational purposes only. I also give my permission for JAN SCAGLIA LMT, with whom I am working with, to discuss information pertinent to my condition(s) and treatment, with my other health care providers. 

Thank you for submitting! ​ I will be contacting you by phone to review the intake information you've provided and to set up your appointment. ​ Have a wonderful day!