Podcast Guest Interest Form

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This podcast will host people from our community to share their experiences with mental illness and treatment for mental illness in order to reduce stigma in our community. The podcast will be called "Syllabus for Overcoming Stigma" or SOS. Please fill out any of the questions that you feel comfortable answering. If it seems like you might be a good fit for the podcast, you will be contacted via email to set up a preliminary 5-10 minute interview.

Do you wish to participate in this survey? *

Please note that by participating in this survey you are consenting to respond to questions that might be sensitive in nature, although you may choose not to respond to any question for which you do not wish to respond. We respect your right to privacy and are committed to protecting the confidentiality of your personal information. This form has been adapted with reasonable measures to prevent loss, misuse and alteration of the information under our control. However, no method of transmission over the internet or method of electronic storage is 100% secure. By selecting yes, you are consenting to the collection, processing and use of the information in accordance to this privacy notice. The information you have provided will be used for communication purposes. The information is collected and stored through Google. Google has its own Privacy Policy, which can be found here: https://policies.google.com/privacy.

Yes

What is your first name?

What is the best email to contact you? *

What is the best phone number to reach you at?

How old are you?

Do you currently live in Washtenaw County or the greater Ann Arbor area?

Yes

Clear selection

What mental illness have you experienced the symptoms of? *

Have you been diagnosed with a mental illness?

Yes

Clear selection

Please state in 1-2 sentences your experience with this illness. *

Have you received treatment for your symptoms?

Yes

Unsure

Clear selection

If you have received treatment, could you share 1-2 sentences about this experience?

Would you like your name to be kept fully anonymous during the podcast? (This will not impact whether you are invited as a guest).

Yes

Maybe

Clear selection

Is it okay if I contact you to ask you a few more questions? If selected to be on the podcast, you would be compensated $100 for your time.

Yes

Clear selection

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