Patient Screening Form

A therapeutic partnership is key to getting to the root cause of chronic illness.

Fill out the form below for a free Zoom consultation.


This form must be completed before the Zoom consultation can be scheduled.
Assessing Commitment
Assessing Readiness to Change

Please rate on a scale of 1 to 5 (1 being not important at all and 5 being very important): How willing are you to:

1. Significantly modify your diet?
2. Take several nutrition supplements each day?
3. Keep a record of everything you eat and drink in a day?
4. Modify your lifestyle? (work demands, sleep habits)
5. Practice a relaxation technique?
6. Engage in regular exercise?
7. Have periodic lab tests to assess your progress?

Next Step - Schedule Your FREE 30-minute consultation

After you submit this form, please click the link below to schedule your call with Trisha.

This button will take you to the calendar app on the Practice Better site.

Important to note:

Trisha Howell MSH, RD, LD/N, IFMCP is not a Medical Doctor. She has her Master’s in Clinical Nutrition, a Registered Dietitian, Licensed Nutritionist and is highly specialized in Functional Medicine through a board-certified physician’s program with the Institute of Functional Medicine (IFM). She is the only board-certified functional medicine nutritionist in Jacksonville, FL and is 1 of 5 in the state of Florida.

She is 100% virtual. She is fee for service practice not insurance based.







Mailing Address:
4446-1A Hendricks Avenue
Suite 219
Jacksonville, FL 32207

Contact us

O: 904-803-5213

Office Hours

By appointment only