Dose of Support: Potential Guest Survey

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* 1. Are you a healthcare professional?

Yes

No

Retired

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* 2. What are your credentials?

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* 3. What type of area do you work/practice in?

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* 4. Are you willing to sign a consent/release to be on a podcast?

Yes

No

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* 5. Do you have access to a computer/smart phone, and simple headphones w/ a microphone (no air pods - poor sound quality).

Yes

No

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* 6. In one word, describe your story:

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* 7. In a few sentences, tell me your story outline:

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* 8. I will reach out to you by email, what is the best way to contact you? (double-check that spelling!)