Straight Path Coaching Intake 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. Important Information: After submitting the form, you will be contacted within 24-48 hours regarding your submission and to schedule your first session. We look forward to supporting you on your journey!
Full Name
*
First Name
Middle Name
Last Name
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
Preferred contact method
Phone call
Text message
Email
How did you hear about us?
*
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
Click save or print to access. Once completed, send it to contact@straightpathcoaching.com
Are you currently on Medicaid?
*
Yes
No, I have insurance through an employer
Not yet, but plan to
Not sure
If on Medicaid, who is your provider?
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
If on Medicaid, please provide your Policy # or ID:
If on Medicaid, please provide the Group #:
Medicaid provider's phone number:
Please enter a valid phone number.
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?
*
Self
Kids
Spouse/Significant other
Other
What is your employment status?
*
Employed
Unemployed
Underemployed
Temporarily Employed (through a temp agency)
Retired or on leave of absence
What's the name of your current employer?
If unemployed, skip the next few questions.
What is your yearly income?
If more than one job, combined the rate for the year.
What's the average number of hours you work per week?
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
In one sentence, where would you like to see yourself 1 year from today?
What circumstances/barriers have stood in your way to achieve the above goal?
Please provide a brief explanation of what motivated you to seek life coaching services.
How soon are you available to start services?
*
-
Month
-
Day
Year
Date
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
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