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What would you like to share with the Radical Self Podcast community?
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About the Podcast
Every episode of the Radical Self Podcast is meant to make listeners think; to encourage them to unearth moments and unlearn lessons that have kept them stuck, disconnected, & unsatisfied.

Every week they listen to featured interviews with inspiring, interesting, down-to-earth people who have found the courage to light up their path toward the life they only once dreamed of; who keep positivity and kindness at the forefront of their actions, and offer motivational tidbits to empower a step forward in others.

If this sounds like you, please fill out the form below.

Name *
As you would like it officially to appear.
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Skype ID *
If there's any detail I'd need clarified, we'll connect by Skype.
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Website
Personal or business - where can we gather more information?
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How did you hear about the Radical Self Podcast?
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Choose 1 or 2 of the following that best describes what's made the most impact for you in your life: *
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If "other" please describe:
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In a short paragraph, please describe your above choices in a bit more detail: *
How long you've experienced this loss/fear, type of struggle you've gone through, etc.
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What steps have/did you take(n) to turn things around for yourself? *
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What's been your biggest lesson from this? *
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Do you practice yoga and/or exercise as a form of self-care? *
Do you have any specialty certifications? If so, please list them. *
Don't worry if you don’t, it’s not necessary but if you do, we'll draw focus to your specialty in some way.
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Any published books and/or other publications/talks you’ve given/written that tie this topic together for you? *
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What days + times are best for us to connect for a 10 minute conversation? *
Please provide 2 options, at least 2 weeks away from today.
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Second option *
Please provide 2 options, at least 2 weeks away from today.
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Choose your times: *
Please select your times for both dates chosen above.
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Would you like to provide any other relevant information?
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Acknowledgement *
I acknowledge that the primary purpose for the Radical Self Podcast is to benefit the audience, and that my participation is for the intent of creating value for them. Although I will not be directly compensated and will be participating at my own choosing, I also acknowledge that I may receive exposure and recognition through my participation. I acknowledge that the audience will be involved through listening to the podcast, and after the fact through access to my interview in recorded format. The timing and specific scheduling of my interview, if I am selected, will have only minimal impact on the potential audience exposure because of the availability of the recording which I can promote as I see fit with my own list.
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Interview Consent & Release *
Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Daisy Jeys and the Radical Self Podcast, its affiliates and agents, to use my still and/or video image and likeness and any interview content from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational purposes and awareness. This consent is given in perpetuity, and does not require prior approval by me.
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Thank you for your interest in sharing your story with us!
Daisy or someone from the team will be in touch with you should we decide to move ahead with your application.
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