Consent to Speak Candidly
Please complete this form to confirm your understanding and agreement to participate in an open and honest conversation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or Affiliation (if applicable)
Role or Position
Purpose of Conversation
*
Please Select
Interview
Feedback Session
Performance Review
Consultation
Other
Date of Conversation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Will this conversation be recorded?
*
Yes, the conversation will be recorded.
No, the conversation will not be recorded.
Please indicate your comfort level with speaking candidly in this setting.
*
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
Is there any topic you do NOT wish to discuss candidly?
Signature
*
Submit Consent
Submit Consent
Should be Empty: