Straight Path Coaching Interest Form
Thank you for your interest in our life coaching services with Straight Path Coaching. This form serves as the first step in our intake process for services. After submitting the form, you will be contacted within 24-48 hours regarding your submission. Upon completion of this form, you will meet with our Mental Health Therapist to undergo a Psychiatric Assessment. To qualify, you must (1) An Adult or Youth (at least 14 years) with a Parent's consent, (2) Medicaid or be Medicaid-eligible, and (3) Willing work Part-time or Full-time. We look forward to supporting you on your journey!
Our Neighbor's Name
*
First Name
Middle Name
Last Name
How did you hear about us?
*
Birthday
*
-
Month
-
Day
Year
Date
Current age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Are you 18 years or older?
*
Yes
No
If you're under 18 years of age, have you signed a Parent Consent Form?
Yes
Not yet, click the below form to download and send to contact@straightpathcoaching.com
Please click the 3 dots on the right and click save or print to access.
Are you currently on Medicaid?
*
Yes
No, I have insurance through an employer
Not sure
Not yet, would like to
What company provides your Medicaid insurance?
*
Please Select
AmeriHealth Caritas Ohio, Inc.
Anthem Blue Cross and Blue Shield
Buckeye Health Plan
CareSource Ohio, Inc.
Humana Healthy Horizons in Ohio
Molina Healthcare of Ohio, Inc.
UnitedHealthcare Community Plan of Ohio, Inc.
Other
Insurance Company Phone number:
This is usually found on the back of the card. Usually the Customer Service number.
Name of the person who carries the insurance
If self, add your name.
Policy # or ID:
Group #:
SSN of the person who carries the Insurance:
(If you're uncomfortable adding, call us at (614) 962-7284 to provide over the phone)
Picture of Medical Card
Browse Files
Drag and drop files here
Choose a file
If you have a picture of your medical card, please add it here.
Cancel
of
What's the number of people in your household?
*
1 - self
2
3
4 or more
Who in your household would be interested in life coaching services?
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Self
Kids
Spouse/Significant other
Other
Are all the options you selected above covered by Medicaid?
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Yes
Some but not all
No, through another provider
Not yet, but would like to
What life coaching services are you most interested in?
*
Personal Development Coaching: One-on-one coaching to reach goals
Adulthood Readiness Coaching - coaching for 14 -21 years old
Career Guidance and Development Coaching - searching for a career
Group Coaching - Lessons and discussions on Life Skills
Not Sure yet
How soon are you available to start services?
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-
Month
-
Day
Year
Date
All participants are required to be assessed by a licensed Mental Health Therapist. Do you agree to be assessed?
*
Yes
No
Not sure, need more information
By checking this box, you agree to receive recurring messages from Straight Path Coaching, LLC, Reply STOP to Opt out. Reply HELP for help. Message frequency varies. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All OPT-IN requests include text messaging originator opt-in data and consent; this information will not be shared with third parties.
I agree
Phone number for text messaging:
By entering your number, you agree to receive mobile messages, Message frequency disclosure, ‘Text HELP for help’, ‘Text STOP to cancel’, Message pricing disclosure
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