Straight Path Coaching Intake Form

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 NameMiddle NameLast Name
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
What's your ethnicity?
How did you hear about us?
Are you a Single Parent?
How many children (under 17 years old) do you have?

Please list names and ages of children (under 17):

Rows	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?
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?
Are you currently on Medicaid? PLEASE NOTE: Services are FREE for Medicaid recipients only.
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.
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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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?
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.
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Women's Single-Parent Support Group

Section 1: Contact Information

Section 2: MEDICAID INFORMATION

Section 3: Acknowledgments