Dear Katie Podcast Guest Application

Dear Katie Podcast Guest Application

We receive many applications to be a guest, so please provide thorough responses. Form submissions are not confidential as they are reviewed by our Podcast Production Team. If you are in need of support, please reach out to the sexual assault counselor hotline (800-656-4673) or the national sexual assault legal hotline (567-7420-8837) .
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Preferred Pronouns*

She/herHe/himThey/themZe/zirOther
Current Relationship Status*

SingleLong time partnerMarriedDivorcedSeparatedPrefer not to sayOther
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Guest's Cell Phone (not agent's cell)*

Area CodePhone Number
Alternate or Agent's Phone (Optional)

Area CodePhone Number
Guest's Primary Email*

Confirmation Emailexample@example.com
Alternate or Agent's Email (Optional)

Confirmation Emailexample@example.com
I am submitting this form primarily as a:*

Guest survivor to share my storyGuest expert/specialist
Would you like to become a TBTN Fan (free) and receive our monthly newsletter?*

YesNo
Guest Details
What is your preferred name for use on the podcast?*
Do we have your consent to use your biography, photo and name on our platforms?*

YesNo
What is your area of expertise or your experience in the field of sexual violence?*
Have you recently published a book, released music, published research or created an artistic work? If so, what is the title and topic? Where is your book or other work available for purchase or viewing?*
Are you known for any other media platforms or public advocacy work? Please describe. *
Do you or your institution/agency/organization have a website showcasing your work? If so, please share the link. *
Do you have a personal website or other webpage that you would like us to review as part of your application? If yes, provide the URL(s). If no, put N/A. *
Please provide LINKS (not just the types or handles) to all of your social media platforms. Put N/A if you have no social media platforms. *
Provide links to other interviews and podcasts you have done. Put NONE if you have not done any other interviews. List any podcasts for which you have recorded interviews that have not been released as of the date you are completing the firm. *
Please upload a headshot photo. This is the photo we would use with your episode release. *

Browse Files

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Your application is evaluated by our team, and your answer to this question is very important. We receive a great number of applications to be on the Podcast. We work to ensure the requests and needs of our listeners are being met with our the content provided by our guests. Please share 4 (FOUR) compelling points you would offer our listeners to support them in their healing journeys and/or understanding of sexual violence issues. Please share anything about you or your story that makes you unique and would standout to our listeners. *
Describe how you will promote your episode should you be chosen as a guest.*
Experience Information

(put NA if you are not a survivor)
Check all that apply below. You may add any additional information in the "Other" field. We know these questions are personal and may be sensitive, but the nature of this podcast can be traumatic and triggering for some. We want to provide the best support for our guests and our listeners.*

Survivor of dating abuse/intimate partner violenceSurvivor of college rape/sexual assaultSurvivor of high school rape/sexual assaultSurvivor of rape/sexual assault by employer or co-workerSurvivor of adult rape/sexual assaultSurvivor of childhood abuse by family member (immediate and/or extended)Survivor of childhood abuse by organization, school, or religious leaderSurvivor of childhood abuse by another personExpert/highly knowledgeable on sexual violence or sexual misconduct of any kindActivistArtistPoetMusicianAuthor/writerExpert/specialistOther
To the best of your recollection, the number of perpetrators who have committed acts of sexual abuse and/or sexual violence against you is (put NA if you are not a survivor):*
On the podcast, we need to focus on just one experience. While it may be hard for you to rank your experiences, if you have had more than one, please describe below the one you would most like to discuss on the podcast. *
In your own words, please describe the experience you would like to discuss on the podcast. Include who was involved; how old you were; what you did at the time about it; what you have done since then and any other information you'd like to share. (Put NA if you are not a survivor). *
When did this experience happen? (May be a specific date or over a period of time) (put NA if you are not a survivor) *
Where did this experience happen?*
Reporting and Any Disclosure

(put NA if you are not a survivor)
Have you discussed the incident you want to discuss on the podcast with anyone before now?*

Yes, in partYes, in fullNoNA
Have you discussed this experience with any of your family members?*

Yes, in partYes, in fullNoNA
If you have a current partner, have you discussed this experience with your partner?*

Yes, in partYes, in fullNoDo not have current partnerNA
If you have discussed this experience previously with anyone else, when and with whom? What was their response? (If not applicable, enter N/A).*
Did you formally report this experience to your school, employer, police, District Attorney, and/or other authorities?*

YesNoNA
If so, to whom did you report? (If not applicable, enter N/A). *
Have you ever discussed this experience with a lawyer/attorney?*

YesNoNA
If any legal authority was notified, was there a criminal investigation?*

YesNoN/A
If there was a criminal investigation, did the case go to trial?*

YesNoN/A
If there was a criminal investigation and/or trial, what was the outcome? (If not applicable, enter N/A). *
If any campus authority was notified, was there an adjudication process?*

YesNoN/A
If there was an adjudication process, what was the outcome? (If not applicable, enter N/A). *
If any legal authority was notified, was there a civil case?*

YesNoN/A
If there was a civil case, was there a resolution? If so, please describe to the best of your ability. (If not applicable, enter N/A). *
Please let us know anything else about your reporting experience or attempt to receive justice. Put N/A if nothing to add here. *
Impact on Survivor's Life

(put NA if you are not a survivor)
Have you ever been harassed or bullied about your experience? If so, please describe.*
Which of the following has your experience impacted? (Check all that apply).*

FriendshipsRomantic relationshipsFamily relationshipsMental healthPhysical healthWorkNone of the aboveNAOther
From the previous question, describe the impact. *
Has the experience resulted in any long-term consequences in your life? If so, please describe.*
Do you think there is anyone who would be upset if they knew you did this podcast and shared this experience? If so, please explain. *
Please describe what steps you have taken to heal and how you would share this information with our listeners?*
Technology Requirements for Podcast Guests
Do you have reliable high speed internet access (WiFi or other)?*

YesNo
Which of the following options do you have for recording audio for the podcast? We will not be able to record if you don't have a computer. Phones are not able to provide sufficient video quality. (Check all that apply).*

HeadsetEarbuds with microphoneExternal microphoneThrough MAC laptop or desktop computerThrough PC laptop or desktop computerOther
Please verify that you are human*
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