Cavite State University: Silang Campus

Informed Consent Form for identifying the client’s psychological status in his/her
present age.

Name of Principal Investigator: Lois Kent J. Balingit

Name of Organization: Cavite State University Silang Campus
Name of Project and Version: INTAKE INTERVIEW QUESTIONS IN COUNSELING

PART I: INFORMATION SHEET

INTRODUCTION
Spearheaded by Lois Kent J. Balingit, BSP-2A student of Cavite State University: Silang
Campus. The interviewer will be administering set of papers to assess the client’s status. The
pieces of information that will be collected from this will aid the interviewer to understand their
standpoint on this matter as well as to proceed to the succession of this document.
Of course, the clients are reminded that they are free to have someone with them as the
means of their comfort while answering. And they are encouraged to ask questions as the
interviewer will take the time to explain any words or questions they do not understand as the
interview process goes along.

PURPOSE OF THE INTERVIEW

The purpose of this intake interview is to determine the mental status of the client at their
present age.

TYPE OF INTERVENTION
The interviewer will be using an interview question to assess the client’s status.

PARTICIPANT SELECTION
The participant of this interview is based from the vicinity of the university and within
reach so any concerns and changes may be applied immediately. The chosen one (1)
participant will solely be the center of this interview and the remaining process until the very
end.
VOLUNTARY PARTICIPATION
Participation in this interview is completely voluntary. Promptly, they are free to choose to
participate without any pressure or coercion in this. They have all the entitlement whether to
withdraw from, or leave, the interview at any point without feeling an obligation to continue.

PROCEDURES
Note that the interview will happen with the presence of the client and their prerogative
to participate in this session. The interviewer will be presenting and ask questions that pertains
to personal information of the client. Every other part of interview there will be a corresponding
break to avoid overwhelming emotion and prepare the client to continue the interview.
At the end, the interviewer will express his deepest gratitude to the client for completing
this session.

DURATION
With the set of questions prepared for the interview, it is estimated that it will take around
30 to 45 minutes of the client’s time.

RISKS

As the present interviewer is heavily responsible for any risks that may happen during
the interview period, they have taken into account that the client may not be in a good mood or
may be in potential discomfort while having the interview. They are not prohibited from
withdrawing or discontinuing this session for the sake of their care.

BENEFITS
This intake interview may help the client to better understand themselves and their
mental status at their current age. This may open the root of any uneasiness, discomfort, and
happiness that they have.

REIMBURSEMENTS

There is no cost for participating in this interview. Any medical expenses resulting from
participation in this session will not be reimbursed by the investigators as they are free to
withdraw anytime they do not feel in the best condition.
CONFIDENTIALITY

All information taken from the interview will be protected. No names or other identifying
information will be used when discussing or reporting data. The interviewer will safely keep all
files and data collected in a secured drive or folder. In effort to maintain the confidentiality of the
information provided by the respondents. The interviewer will assign pseudonyms upon the
input in the analysis of the research. Rest assured that once the data has been fully analyzed it
will be destroyed.

SHARING THE RESULTS

The result of this interview will be just circulating around the interviewer and the head
psychologist of this institution.

RIGHT TO REFUSE OR WITHDRAW

In this interview, you have the right to withdraw anytime. The interviewer will not force
you to answer the questions about the study. The client who agreed to participate will have the
right to review their answers after the interview. If you didn’t like the answers you provided, you
can ask the researcher to remove it.

WHO TO CONTACT
For further questions, feel free to contact the following:

Lois Kent J. Balingit

09276486212
LoisKent.Balingit@cvsu.edu.ph

PART II: CERTIFICATE OF CONSENT

I have read the foregoing information, or it has been read to me. I have had the opportunity to
ask questions about it and any questions I have been asked have been answered to my
satisfaction. I consent voluntarily to be a participant in this study.

Print Name of Participant:

Signature of Participant: ___________________
Date: 3/18/2023
STATEMENT BY THE RESEARCHER OR PERSON TAKING CONSENT
I have accurately read out the information sheet to the potential participant, and to the best of
my ability made sure that the participant understands that the following will be done:

1. with their presence and insights in this interview.

2. this will happen in the vicinity of the school.
3. the agreement of both parties must be fulfilled.

I confirm that the participant was given an opportunity to ask questions about the study, and all
the questions asked by the participant have been answered correctly and to the best of my
ability. I confirm that the individual has not been coerced into giving consent, and the consent
has been given freely and voluntarily.
A copy of this Informed Consent Form has been provided to the participant.
Print Name of Researcher or person taking the consent
Lois Kent J. Balingit
Signature of Researcher or person taking the consent
_________________________
Date: 3/18/2023