Tanielle L.A. Brown

### Personal Information

Full Name:*

Email Address:*

Phone Number:*

Are you a current or past client of Eclectic Therapeutic Connections INC?*

Current Client Past Client Not a Client

### Business Information

Do you have your own business?*

Yes No

##If Yes, please provide the following details:*

Business Name:*

Business Website (if applicable):*

Services Provided by Your Business:*

How do your services help other moms, kids, and families stay together or be supported?*

##If Yes, please provide the following details:*

what is your dream business?*

### Goals & Challenges

What is on your bucket list of things you want to accomplish?*

*What do you feel is a challenge to achieving what's on your bucket list?*

*Why is being in a network group of moms so important to you?*

What do you want to get out of being a part of this network?*

### Mom Coaching Services

Are you seeking a Mom Coach?*
A Mom Coach is someone who is a wife, coach, but mainly focuses on helping you become the highest version of yourself as a mom. This service is designed to support you in navigating challenging times, rising through adversity, and achieving your greatest potential as a mother. If you are interested in this additional service, please select your preferred session length below and make the payment via Cash App to $TanielleLABrown.

Session Options (Please select one):*

1 Hour Session - $95* 1 Hour 30 Minutes Session - $125* 2 Hour Session - $150*

*After selecting your session and making the payment, my Executive Assistant, Adela Torres, will reach out to you to send you the necessary paperwork for life coaching. Please note that life coaching is not the same as mental health therapy. It focuses on making changes in your life without addressing mental health diagnoses. Adela will also assist you with scheduling your sessions.*

*I work 7 days a week, so I offer flexible scheduling options to meet your needs.*

### Motivational Speaking Services

Would you like to request Motivational Speaking at your women's group events or for young women (ages 14 and up)?*

I offer motivational speaking services designed to empower and encourage women and young women to be their greatest version.

Session Options (Please select one):*

1 Hour Session - $1,000* 2 Hour Session - $2,500*

*If you are interested, please select your preferred session length above and make the payment via Cash App to $TanielleLABrown. My Executive Assistant, Adela Torres, will follow up with you to finalize the details.*

### Family Information

How long have you been a mom?*

How many children do you have?*

Ages and Genders of Your Children:*

Child 1: Age

Child 1: Gender

Child 2: Age

Child 2: Gender

Child 3: Age

Child 3: Gender

Do you live inside or outside of the USA?*

### Package Selection

*Which Package Would You Like to Sign Up For?* (Please select one)

### Additional Information

If selecting the Moms' Biz Boost package, would you like to schedule your frequency therapy sessions and VR Therapy sessions now? (Yes/No):

YES NO

*How did you hear about the CEO BOS MOM Network?*

### Payment Method

Cash App Username (for verification):*

*By signing up, you agree to the terms and conditions of the CEO BOS MOM Network.*

Ready to Take the Next Step?*
- Send your payment to *Cash App: $TanielleLABrown*
- After making the payment, please submit this form to tla@etccounseling.com or return it directly through our website.

Thank you for joining the CEO BOS MOM Network, where Moms Empower Moms in Business!

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