Straight Path Coaching Interest Form

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 NameMiddle NameLast Name
How did you hear about us?
Birthday

MonthDayYear
Date
Current age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Are you 18 years or older?
If you're under 18 years of age, have you signed a Parent Consent Form?
Please click the 3 dots on the right and click save or print to access.
Are you currently on Medicaid?
What company provides your Medicaid insurance?
Insurance Company Phone number:
This is usually found on the back of the card. Usually the Customer Service number.Format: (000) 000-0000.
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

If you have a picture of your medical card, please add it here.
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What's the number of people in your household?
Who in your household would be interested in life coaching services?

Other
Are all the options you selected above covered by Medicaid?
What life coaching services are you most interested in?
How soon are you available to start services?

MonthDayYear
Date
All participants are required to be assessed by a licensed Mental Health Therapist. Do you agree to be assessed?
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.
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 disclosureFormat: (000) 000-0000.
Should be Empty: