Dear Katie Podcast Guest Application

Dear Katie Podcast Guest Application
Legal 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
Cell Phone*

Area CodePhone Number
Alternate Phone (Optional)

Area CodePhone Number
Primary Email*

Confirmation Emailexample@example.com
Alternate Email (Optional)

Confirmation Emailexample@example.com
I am submitting this form 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 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. *
Please upload 1-2 headshots. *

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Survivor Experience
In our interview, we can use your real name or a pseudonym to protect your privacy. We will not publish your biography, photo, or full name on any of our platforms without your consent and express permission. What is your preferred name or pseudonym for use on the podcast?*
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/writerNone of the aboveOther
To the best of your recollection, the number of perpetrators who have committed acts of sexual abuse and/or sexual violence against you is:*
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 specific 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. *
When did this experience happen? (May be a specific date or over a period of time) *
Where did this experience happen?*
Reporting and Any Disclosure
Have you discussed the incident you want to discuss on the podcast with anyone before now?*

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

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

Yes, in partYes, in fullNoDo not have current partner
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?*

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

YesNo
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). *
Impact on Survivor's Life
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 aboveOther
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. *
Is there anything else we should know about your experience?*
Technology Requirements for Podcast Guests
Do you have reliable internet access (WiFi or other)?*

YesNo
Which of the following options do you have for recording audio for the podcast? (Check all that apply).*

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