Pure Life Ministries Residential Reference Form

Your Name*

First NameLast Name
Your Email*
example@example.com
Name of Applicant*

First NameLast Name
Your relationship with applicant (pastor, counselor, friend, etc.)*
How long have you known the applicant?*
How would you describe your present relationship with the applicant (good, strained, don't know him that well, etc.)?*
Does the applicant claim to know Jesus Christ as his personal Lord and Savior?*
In your opinion, what are the applicant's motives for coming to this program?*
Is it the applicant's desire to come to our program, or is it someone else's?*
Has the applicant come to you recently for spiritual counsel? If so, what were the results (followed counsel, ignored advice given, became defensive, etc.)?*
Does the applicant have problems submitting to corrective guidance from others? Please explain.*
What are the biggest problems you anticipate the applicant will have while in our program?*
What is the level of commitment (if any) to the church he is involved in?*
Would you consider the person responsible and mature regarding his personal finances?*
This program utilizes biblical homework as a significant aspect of the counseling process. Does the applicant have any reading, comprehension, or academic difficulties we should be aware of?*
What would be your reaction if, after several months, you heard that the applicant had left our program and returned to his old lifestyle?*

ShockedRather surprisedSlightly surprisedNot surprisedExpected it
What is the applicant's most serious weak points (emotionally and spiritually)?*
What are his strongest points?*
Are you aware of other problems concerning the applicant that we should know about?*
Do you recommend that we accept the applicant into our program?*

YesNo
Please explain.*

	1 (Never)	2	3	4	5 (Always)
Teachable
Demanding
Stable
Growing spiritually
Moody
Responsible
Submissive
Humility
Open/real
Legalistic
Cooperative
Troublesome