Staff Reference Form

Please accept our thanks in advance for giving your frank and confidential opinion of his/her suitability for this position.

If you are human, leave this field blank.

Applicant’s name:

Date

How long have you know the applicant?

In what capacity have you known the applicant?

Is this the type of person you would want as a counselor for a child of your own?

Yes

No

Unsure

What three words would you use to describe this person’s strengths?

Ability to Accept Supervision and constructive criticism: excellent good fair poor no basis for judgment

Appearance: excellent good fair poor no basis for judgment

Ability to connect with Children: excellent good fair poor no basis for judgment

Communication Skills: excellent good fair poor no basis for judgment

Consideration for others: unusually thoughtful usually considerate rarely considerate selfish no basis for judgment

Energy: excellent good fair poor no basis for judgment

Enthusiasm: excellent good fair poor no basis for judgment

Friendliness: excellent good fair poor no basis for judgment

Dependability: excellent good fair poor no basis for judgment

Health: excellent good fair poor no basis for judgment

Humor: delightful good inappropriate humorless no basis for judgment

Integrity: very trustworthy usually trustworthy occasionally trustworthy untrustworthy no basis for judgment

Maturity: very mature appropriate somewhat immature very immature no basis for judgment

Motivation very ambitious eager average no motivation no basis for judgment

Leadership: always takes initiative sometimes leads follows never leads no basis for judgment

Loyalty excellent good fair poor no basis for judgment

Responsibility: always sometimes avoids never accepts no basis for judgment

Self Confidence: healthy self image needs some support appears overly confident needs much reassurance no basis for judgment

Social Attitude: excellent good fair poor no basis for judgment

Teaching Ability: excellent good fair poor no basis for judgment

Tolerance: excellent good fair poor no basis for judgment

Overall Rating excellent good fair poor

Do you have any additional information that may be helpful in our evaluation of this applicant?

YOUR Full Name

YOUR Email Address

YOUR School or Business

YOUR Address

Daytime contact phone number

Evening contact phone number