Her Empowered Divorce Live Intake Form

Live Show Intake Form

The Divorce Coalition - Enhancing the Divorce Process for Domestic Abuse Survivors Through Education and Awareness of Divorce Professionals
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Title *
Company Name*
Email*
example@example.com
Cell Phone Number *
Please enter a valid phone number.
We strive to disrupt the conventions that allow direct physical, emotional, financial abuse and all other forms as well as abuse in the form of false allegations and manipulations of all kinds. Do you agree?*

YesNo
Since our mission is to enhance the divorce process and experience for abuse survivors, our show is created for divorce, court and other professionals involved in the process. Please make sure that your topic is directed to create awareness and educate these professionals as opposed to material that is specifically created for the victim/survivor.*

I agreeI disagree
What Topic Do You Want To Talk About or That We Agreed To Talk About? Do you have a suggested episode Title? Nor do we use profanity.*
What Are 5 Questions Should We Ask You On This Topic that Can Educate Divorce professionals*
Can you provide 5 bullet points about yourself that you would like us to include in your introduction?*
Can you provide a brief description of what your episode will be like so we can be use it for promotion?*
Please attach you headshot*

Cancelof
Please attach a short bio*

Cancelof
Please provide the write up you would like included in the show notes including website and social media links.*
I understand that this video is the sole property of the Divorce Coalition. Any use of it, must be approved by the Divorce Coalition.*

yesno
Is there any other information you would like to share?*

Optional: I would like to make a tax deductible donation to the Divorce Coalition, a 501c3 non-profit organization created to enhance the divorce process for domestic abuse survivors.

USDDescription

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

This promises to be a great experience! The show is pre-recorded and the recording will play on Tuesday at 11am EST. The recording is unedited audio and video. So remember your mic is live throughout. We will be using Zoom to record. The show will air on multiple channels of radio and TV.

Please also test your equipment the day before the show to prevent any issues. Also do any computer updates and reboot your computer the day before. Separate microphones and headphones/earbuds greatly increase the quality. If the sound and video are not good, we will need to re-record.

Your topic must relate directly to the mission of the divorce coalition - to educate divorce professionals in topics of abuse to help them prevent re-traumatization of victims in the divorce process. It should not consist solely of self-promotional information.

Please make sure that you are in an area free from of noise and distractions (ex. pets and other people), and that you and your background are professional and camera ready.

The live links for your followers will come from CeCe Shatz before the show that you can use for promotion, and the YouTube Link will come afterwards. The Youtube Link will be posted on the Divorce Coalition website www.divorcecoalition.com

We will send you some social media that you can use to the promote the show closer to the show air date. You will receive the YouTube links after.

Thank you so much. we look forward to our recording time together.

The Divorce Coalition
I agree to post this live and recorded episode and the Divorce Coalition though my marketing channels - email, social media, etc.*

Powered by Jotform SignClear
Should be Empty:

Live Show Intake Form