Apply - Jem Barbaros™

Jem Barbaros Coaching

Initial Application

Please complete this brief preliminary application. All information is confidential, used solely for vetting, and secured. Note that this intake form is for evaluation only and does not constitute a service agreement.

First Name *

Last Name *

Date of Birth *

Email Address *

Phone *

GenderMaleFemaleOther

City *

State/Province *

Country *

Goals & DesiresWhat do you hope to get out of coaching with Jem Barbaros?

NotesAnything else you'd like to share, or questions you have?

Mental Health Safety Information *As a parts work coach, I do not diagnose or treat mental illness, as these require a qualified professional. Please indicate whether you have or have had any acute mental health crisesNo active or past acute mental health crisesI have acute mental health crises, and am not seeking professional treatmentI have or have had acute mental health crises, but am receiving or have received treatment (if so, please explain)