APPLICATION | JNB Ministries

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First name

Last name

Phone

Are you currently in an abusive relationship or recently separated from one?

Yes

Do you have immediate safety concerns that require crisis intervention?

Yes

Have you experienced physical, emotional, psychological, financial, or spiritual abuse? (Check all that apply)

How long have you been dealing with this situation?

What is your current professional role or public position?

How would public knowledge of your situation impact your career or reputation?

Do you have media attention or public scrutiny in your life? (If yes, please explain)

Are there legal, contractual, or professional obligations that complicate your situation? (If yes, please explain)

What level of confidentiality do you require for this coaching relationship?

Do you have a trusted support system (friends, family, colleagues) who know about your situation?

Yes

I don't know

Have you worked with other therapists, counselors, or coaches regarding this issue?

What specific outcomes are you hoping to achieve through this coaching program?

How much time can you realistically commit to your healing journey each week?

What is your biggest fear about moving forward with recovery?

What role does your spiritual life play in your current situation?

On a scale of 1-10, how ready are you to take action toward change?

Is there anything else about your situation that would be important for Dr. Jan to know as she considers whether this program is the right fit for your needs?

Schedule a Free Discovery Call

January 2026

Week starting Sunday, January 25

Time zone: Coordinated Universal Time (UTC)Phone call

Monday, Jan 26

10:00 AM - 11:00 AM

11:00 AM - 12:00 PM

12:00 PM - 1:00 PM

1:00 PM - 2:00 PM

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