Media Request Form

First name*

Last name*

Email*

Phone*

Organization/Media Outlet Name*

Website or Social Media Handle*

Type of Request (Check all that apply)*

Interview Request

Book Review/Feature

Speaking Engagement

Press Release Inquiry

Partnership/Collaboration

Other (please specify)

Briefly describe the focus of the feature, interview, or event. *

Preferred Format (Check one)*

Live Interview (In-person)

Live Interview (Virtual)

Pre-recorded Interview

Written Q&A

Podcast Feature

Other (please specify)

Intended Publication/Release Date*

Where will this content be published/broadcasted?*

Estimated Audience Size/Reach*

Any key topics or questions you’d like covered?*

When do you need confirmation by?*

Any other relevant details (e.g., book copies needed, speaking honorarium, event logistics).

I understand that submitting this form does not guarantee approval of my request.

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Berkeley CA 94705

415-580-1908

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