Feedback Form | Girlfriendism

SECTION 1: About You (The Woman & The Doctor)

Full Name (as you would like it announced)

Credentials / Professional Title

Cultural Background / Diasporic Identity

Specialty

Business or Organization (if applicable)

Website

Social Media Links

Link to Professional Headshot Upload (Add Link or to email instead, note 'N/A')

Link to Short Bio (150–250 words) (Add Link or to email instead, note 'N/A')

SECTION 2: The Girlfriend Conversation

Why does this type of sister girlfriend doctor space resonate with you?

When you imagine taking off your lab coat/blazer/heels and speaking woman-to-woman, what feels most important to share?

Please add any additional comments or responses for 'other'.

What perspective do you bring as an Afro-diasporic woman doctor that is often unheard?

Preferred Recording Window:

Thursday (6–8 PM AST)

Saturday (4–6 PM AST)

Flexible

Additional Available Dates (Next 4–6 Weeks), If Any

Time Zone

SECTION 3: Media Consent & Safe Space Agreement

Media Consent & Safe Space Agreement

I understand this podcast is conversational and affirming in tone.

I grant permission for All Docs on Deck and its affiliates (Girlfriendism International & The Unstuck Strategist) to record, edit, and distribute my audio and video for podcast and promotional use.

I grant permission for my name, likeness, and submitted materials to be used in marketing related to the podcast.

I understand participation is voluntary and unpaid.

Please type your name and date to grant consent to the above. Name & Date:

SECTION 4: Staying Connected

I am open to staying informed about future gatherings, collaborations, or collective opportunities for Afro-diasporic women doctors.

Yes

Maybe

Not at this time

As a woman - not as a doctor - what is your personal ritual for staying mentally, emotionally, and spiritually well?

Would you like to be added to our private network for sister girlfriend doctors?

Yes

No

All Docs on Deck Podcast Guest Intake & Consent Survey

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