Women's Single-Parent Support Group
Thank you for your interest in the Women's Single-Parent Support Group. Please fill out the form below if you are interested in signing up. Sessions will begin early September 2025. To qualify, you must: (1) Be a single mother of dependents (17 years and younger). (2) On Medicaid or Medicaid-eligible. (3) Willing to participate in monthly group sessions on Saturday mornings (time and location TBD). (4) Work 1-on-1 with a Personal Development Coach on a weekly basis. CHILDCARE WILL BE PROVIDED for those that need it. We look forward to supporting you on your journey!
Section 1: Contact Information
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
What's your ethnicity?
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Prefer Not to Answer
How did you hear about us?
*
Are you a Single Parent?
*
Yes
No
Not yet; expecting
How many children (under 17 years old) do you have?
*
Please list names and ages of children (under 17):
*
NAME
AGE
Child 1:
Child 2:
Child 3:
Child 4:
Child 5:
Child 6:
Will you need childcare during the time you will be in your group session?
*
Yes
No
Maybe
If yes or maybe, please list which children above you would need childcare for?
Are you currently working with a life coach at Straight Path Coaching?
*
Yes
Not yet, this is my first time signing up for services
Not sure; or in process
Are you currently on Medicaid? PLEASE NOTE: Services are FREE for Medicaid recipients only.
*
Yes
Not sure
No (if you select this option, you may not be eligible for FREE services)
Not yet, would like to
Section 2: MEDICAID INFORMATION
If this is your first time signing up with Straight Path Coaching, please fill out the insurance information needed below. If you've already filled this out, please skip to Section 3. PLEASE NOTE: This is service is paid for MEDICAID recipients only.
Please provide the company name of 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
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If you have a picture of your medical card, please add it here.
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Section 3: Acknowledgments
Along with the Group Sessions, you will be encouraged to pair up with a Personal Development Coach to help you achieve your individual goals. Is this okay with you?
*
Yes
No
Maybe, I'd like to learn more.
How soon are you available to start services?
*
-
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
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