top of page
Untitled design.png



The topic of this discussion

The Purpose of This Interaction

It can be difficult to initiate contact in certain circumstances and that is the reason I am using the Z Form. 

I am initiating contact because I want to:  

  • I have good intentions

Facts and Hopes About Our Interaction

Political correctness and cancel culture hinder communication and genuine human connection. Real connections and effective communication require openness and courage.

  • We are all different, with unique upbringings and experiences

  • We both take responsibility for our own actions or inactions

  • We take this opportunity to use our “voice”

  • We attempt to improve understanding and connection

  • We may just agree to disagree


  • The risks, benefits, “side effects” and alternatives of using this Z Form are assumed and understood by me.

  • The content of this Z Form is an accurate representation of my emotional experience and what I intend to communicate to you.

  • I understand that I may terminate the interaction at any time and that you are also entitled to do the same by revoking this consent.

  • I understand that this interaction may not be politically correct.  


Z Form is not responsible in any way of how you chose to use this form. It may provide peace of mind for constructive dialogue for any style of interaction. Both parties assume responsibility for the use and outcome(s) resulting from this form. Once both parties agree to the interaction, it is solely up to the parties to organize/plan how to proceed. 

Information and Signature

My signature below attests that and that I am not being coerced or threatened, that I am in a sound state of mind and I am not under the influence of substances legal or illegal. I understand and agree with all the above statements. By proceeding with the use of this form, I am consenting to all of the above. 

1st Party Signature


Receiving Party Information and Signature

2nd Party Signature


Additional Comments (Optional, to be filled out by recipient)  : 


Witness 1 :

Witness 1 Signature


Witness 2 :

Witness 2 Signature

bottom of page