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. 

Your Signature

156 East Avenue, second floor

Norwalk, CT 06851

info@mysite.com

Tel: 203.984.0407

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© 2016 by Jan Scaglia