Work With Jon - Jon Mitchell LLC

Please fill out this brief questionnaire and you will be redirected to schedule your call. All responses are confidential and HIPPA compliant.

Your Full Name *

City and state which you currently reside.

City *

State *

Phone number *

Email address *

Date of birth *

Gender *

Occupation *

How did you hear about us?

What do you hope to achieve in your visit with me? *

How would you rate your sleep from 1-5? *

How would you rate your focus from 1-5? *

How would you rate your energy from 1-5? *

If you had a magic wand and could erase 3 problems related to your health, what would they be? *

Problem 1
Problem 2
Problem 3

How confident are you of your ability to organize and follow through on health related activities? *

If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to fully engage in improving your health? *

How much ongoing support and contact (e.g. telephone, email correspondence) from your professional staff would be helpful to you as you implement your personal health program? (5 being the need for more frequent contact) *

Are there any Facebook groups or podcasts that you like to follow?This question is required. *

"Thank you for taking a few moments to complete these questions."

After clicking the button below, you will be redirected to schedule your health assessment call.