You can always press Enter⏎ to continue
Clinical Conversation Application
Please complete the following form to apply to be on the Reimagining Love Podcast as part of a Clinical Conversation.
Apply now
1
How It Works
*
This field is required.
Thank you for applying to experience a Clinical Conversation on Reimagining Love with Dr. Alexandra Solomon.
This show is devoted to bringing Relational Self-Awareness to life, and these special clinical conversations are an opportunity for listeners to learn how to walk the talk! Although the relationship challenge, struggle, or pain point that you are bringing forward belongs uniquely to you, these episodes will serve listeners by offering validation, advice, and/or a new perspective.
If you would like to discuss a relationship challenge on the show, BOTH you AND your intimate partner/parent/sibling/friend/etc. will need to complete an application.
All identifying information will remain anonymous on the show. If your application is selected, someone from our team will reach out for a screening phone call. Dr. Solomon will also want to connect with you about a week after we record, so we can debrief the experience together.
Note: If you would like to discuss appearing on Reimagining Love as a guest expert, do not complete this application. Instead, please email the executive producer, Elizabeth, at elizabeth@dralexandrasolomon.com.
Do you still want to fill out this clinical conversation application?
YES
NO
Previous
Next
Submit
Press
Enter
2
Full Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
3
E-mail
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
4
How old are you?
Previous
Next
Submit
Press
Enter
5
Where do you live?
City, state, country, territory, etc.
Previous
Next
Submit
Press
Enter
6
How would you describe your socioeconomic status?
Lower Class
Upper Class
Middle Class
Wealthy
Previous
Next
Submit
Press
Enter
7
What is your gender?
Previous
Next
Submit
Press
Enter
8
What is your race/ethnicity?
Previous
Next
Submit
Press
Enter
9
How would you describe your sexuality?
Previous
Next
Submit
Press
Enter
10
With whom do you live?
Previous
Next
Submit
Press
Enter
11
Are you working outside of your home? If so, what do you do for work?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
12
What is your relationship status? (for example married, single, widowed, dating)
Previous
Next
Submit
Press
Enter
13
If you are partnered, what is their first name and how long have you been together?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
14
Does your partner work outside of the home? If so, doing what?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
15
What is going well in your life right now?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
16
Tell us about the relationship challenge that you are hoping to discuss with Dr. Alexandra Solomon.
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
17
What are you hoping to gain by being a guest on
Reimagining Love with Dr. Alexandra Solomon
?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
18
How familiar are you with Dr. Solomon’s work?
(i.e. read her books, follow her on social media, have taken one of her e-courses, seen her speak)
Previous
Next
Submit
Press
Enter
19
How did you hear about this opportunity?
Previous
Next
Submit
Press
Enter
20
RELEASE, CONSENT AND LICENSE OF RIGHTS
*
This field is required.
You need to read the terms below and click "I accept" in order to submit your clinical conversation application
Previous
Next
Submit
Press
Enter
21
Newsletter
Would you like to be added to Dr. Solomon's newsletter for relationships tools, resources, updates about the podcast, and more?
Yes, subscribe me to this newsletter.
No, thank you.
Previous
Next
Submit
Press
Enter
Should be Empty:
Podcast Listener Question Application
[Edit]
Question Label
1
of
21
See All
Go Back
Submit