Enrollment Form

Breakthrough Coach Full Name*
Brealthrough Coach Email Address*
Date of Call*
MM slash DD slash YYYY
Full Name of Client*
First Last
Email Address of Client*
Type of Client*
Number of Applications based on Green Light Guarantee Calculator:*
How many hours did the client purchase?*
How did the client pay their initial payment?*
Upload confirmation of the wire transfer*
Max. file size: 50 MB.
Additional notes on the wire transfer payment
Stackable Discounts Client is eligible for*
- $150: Payment for BT Call
- $500: Payment for BT Call with Kaneisha
- $200: Decisiveness Discount - enrolled within 48 hours of the Breakthrough Call
- $100: Upfront Payment Discount - paid upfront for an AA or HC 20+ hour package
- $100: Check or Wire Transfer Discount - paid upfront for an AA or HC 20+ hour package via check or wire transfer
- Not eligible for any discounts
Hourly Coaching 10-hour packages are NOT eligible for any stackable discounts besides the payment for their Breakthrough Call.
What is the client's payment plan? Are there any followup actions needed to complete the process of collecting this person's payment(s)?*
How much was the client's initial payment?*
Please indicate other mode of payment
Any special bonuses for the client?*
Please indicate bonuses for the client
What degree(s) are the applicant applying to?*
What are their career goals?*
List target schools and deadlines discussed on the Breakthrough Call*
Is this client especially anxious or nervous? (i.e regarding deadlines, programs, consultant, etc.)*
Has this client expressed a preference for a consultant?
- Yes
- No
Which consultant/s did the client express preference to?*
Engagement Start Date*
MM slash DD slash YYYY

This should be a Wednesday at least 24 hours away.
Referral Source
Name of Referrer*
Indicate your other referral source here*
Notes from Breakthrough Coach (optional)

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