Clone of Single-Parent Support Group

Men's Support Group

Thank you for your interest in the Men's Support Group. Please fill out the form below if you are interested in signing up. Sessions will begin in February 2026. To qualify, you must: (1) Be a male (single or married) in the Columbus, OH area (2) On Medicaid or Medicaid-eligible (if you would like free 1-on-1 coaching). (3) Willing to participate in monthly group sessions on the 3rd Saturday of each month (time TBD). (4) Work 1-on-1 with a Personal Development Coach on a weekly basis. FOOD WILL BE PROVIDED. 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 currently working with a life coach at Straight Path Coaching?
Are you currently on Medicaid? PLEASE NOTE: The weekly 1-on-1 coaching services are FREE for Medicaid recipients only. If you're ineligible for Medicaid, and interested, please let us know.
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 or ineligible for Medicaid, please skip to Section 3. PLEASE NOTE: The 1-on-1 Personal Development Coaching service is free 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 Medicaid card is unavailable):
(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.
Cancelof
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 who are on Medicaid, 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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Men's Support Group

Section 1: Contact Information

Section 2: MEDICAID INFORMATION

Section 3: Acknowledgments