Booked and Bougie MD/PhD Circle Application

Booked and Bougie MD/PhD Circle Membership Form

Complete the form below to request your membership. You must complete all the fields to be considered. Please take your time and answer the questions thoroughly; one word or short answers will not be accepted.
Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Are you a Black woman?*

YesNo
How did you hear about us?*

A Friend or colleaugeTiktokFacebookInstagramLinkedInOther
What is your current role or title?
Which best describes your profession?

Medical Doctor (MD, DO)DentistPsychologist / Therapist / Counselor (LCSW, PsyD, LMFT, etc.)Academic / Researcher with a PhD or EdDPsychiatric Nurse / NPChiropractorOther (please specify)
If you chose other, please specify your profession below
Please list any degrees or certifications you hold (e.g., MD, PhD, LCSW, PsyD, NP, etc.):
Are you currently practicing or working in your field?
What does luxury mean to you beyond material things, and how do you embody that in your daily life?
This community was created for the 92% of Black women who supported Kamala Harris. Does this reflect your political values and the kind of sisterhood you’re seeking?*

Yes, absolutelyI respect that, but I’m not sure I align politicallyNo, we are not alignedI did not vote
Why are you interested in joining The MD/PhD Circle?
What are you currently seeking more of in your life or professional journey? (Check all that apply)*

Rest and nervous system regulationCommunity with aligned Black womenEmotional and spiritual healingNetworking and mentorshipSupport navigating burnout or transitionsInspiration and soft life practices
How do you currently care for your mental and emotional well-being?
What are your thoughts about gossip, and how do you normally handle conflict? Please provide a detailed example of how you managed conflict with another woman in recent memory. What was the result?*
What do you hope to give to this space?
This space is designed to be free of performance, ego, and toxicity. Are you open to participating with vulnerability, softness, and mutual care?

YesI'm willing to grow into thatI'm unsureNo
Is there anything else you’d like us to know as we review your application?
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I understand that my information will not be shared outside of membership purposes.
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Booked and Bougie MD/PhD Circle Membership Form

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