EmailMe Form - New Client Intake

Client Information
Client's Name *
First Last
Client's Email *

Confirm Client's Email
Organization/Business Name
Type the name of your organization/business (if applicable)
How did you hear about coaching with Five Capitals? *
What kind of coaching will you be receiving? *
Certification Payment Preference *
If paying two installments, the first installment is due upon registering and the second is due 30 days later.
Who is your coach? *
Coach's Name *
Billing Details
If you know who your coach is, please enter the billing information you have agreed to with your coach. If you are unsure, please contact your coach directly.
Billing Frequency *
Billing Amount *
$ Dollars
Please enter amount according to frequency (ex. if monthly enter the monthly amount).

If you are splitting your billing please enter the total here and tell us in the Notes section how this will be split.

NOTE: A standard 3.9% transaction fee will be added to your billing amount for credit card payments. A 1.5% transaction fee will be added to your billing for ACH draft.
Billing Start Date *
MM / DD / YYYY
If unsure, enter 1 week prior to the date you hope to start your coaching.
Billing End Date
MM / DD / YYYY
If this is unknown, leave this field blank.
Billing Contact *
Billing Contact Name *
First Last
Billing Contact Email *

Confirm Billing Email
Notes about your billing/coaching: *
If there is nothing else, please enter "none". If you chose billing is split between yourself and someone else, please details the split amounts here.
Billing Phone Number *
### - ### - ####
Enter your phone number.
Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Enter the billing address associated with your billing method.
Billing Method *
Credit Card *

Card Number

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ACH (Bank Draft)
Name on Account *
Bank Name *
Routing # *
Account # *
Consent *
I agree to receive communication and marketing emails from Five Capitals.
Terms and Conditions *
By submitting this form I confirm that I have read and agree to the terms and conditions of coaching with a Five Capitals coach.
Click here to view the terms and conditions.
Signature *
Clear
Coaching and Workshop Fees are based on the coaching and/or speaking engagement and are billed monthly, as a lump sum or in installments.

Monthly fees will be charged at the beginning of each month for that current month’s coaching services. As coaching is a retained service, monthly fees will be billed regardless of if an appointment has been canceled or rescheduled. If an extended absence from coaching is required, the client understands that they must alert Five Capitals at least 30 days in advance to arrange a “pause” from their contract. All travel expenses, training materials, meals and parking incurred by the Coach unless agreed upon in advance by the Client are to be paid/reimbursed by the Client. I understand that I will receive a monthly sales receipt in the amount according to the terms in this agreement and that payment is due upon receipt.

In addition to the coaching fee, all payments include a 3.9% transaction fee for credit card payments, or a 1.5% transaction fee for ACH draft. Late payments are subject to a $25 late fee.

By signing above I authorize Onward Initiatives, LLC {dba Five Capitals} to debit my account as outlined above for the Coaching Fees , plus a 3.9% transaction fee for credit card payments, or a 1.5% transaction fee for ACH draft, for the term of this agreement. I understand that drafts will occur on the first of each month for that current month’s coaching and that I will receive a receipt via email for each payment.

Client Information

Billing Details

ACH (Bank Draft)