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DR. LEIA ANDERSON

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Patient Intake Form for Holistic Counseling with Dr. Leia Anderson, ND, MS, VPD

Personal Information

First name*

Last name*

Birthday

Month

Day

Year

Phone*

Email*

Address

Emergency Contact (Name + Number + Relationship to You):

Health & Wellness History

What brings you to holistic counseling at this time?*

Please describe any current mental, emotional, or physical concerns:

Have you had previous counseling, therapy, or holistic health support? If yes, please describe briefly:

Are you currently under the care of another healthcare provider? If yes, please specify:

Mind-Body-Spirit Connection

On a scale of 1–10, how connected do you feel to your mind:

On a scale of 1–10, how connected do you feel to your body:

On a scale of 1–10, how connected do you feel to your spirit/sense of purpose:

What practices do you currently use for self-care or healing? (Check all that apply)

Meditation

Yoga

Prayer

Journaling

Exercise/Dance

Energy Work

Herbal Remedies

Nutrition

Nature Time

Other

What do you hope to explore or gain through our work together?

Additional Information

Occupation:

Relationship Status:

Children (if any):

Spiritual/Religious Affiliation (if any):

Anything else you would like me to know?

Consent & Agreement

I understand that Dr. Leia Anderson provides holistic counseling services that integrate mental, emotional, and spiritual support, but does not replace conventional medical care. I agree to participate willingly in this process and understand that confidentiality will be maintained.

Signature*

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CONTACT

INFO

717-205-5544

info@drleiaanderson.com

Lancaster, Pennsylvania

AVAILABLE HOURS

By Appointment

Book an Appointment Online

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