Supervision Reference Check
Applicant Name
*
First Name
Last Name
Reference Name
*
First Name
Last Name
Reference Phone Number
-
Area Code
Phone Number
Reference Email
example@example.com
What is the nature of your relationship to the supervision candidate?
Approximately how long have you, or did you, work with the candidate in a professional setting? Exact dates aren't necessary.
Please offer a brief description of the applicant's strengths.
Please offer a brief description of the areas the applicant may benefit from added support.
Considering the legal liabilities that might come with a supervisory relationship, would you feel 100% comfortable having this candidate work under your own professional license? Please share details, if helpful.
If they were to work under your license, would you feel comfortable with how this applicant reflects on your own professional reputation? Please share details, if helpful.
Is there anything else you'd like to add, or anything else that would be helpful for us to consider?
Please use your mouse or trackpad to write your signature below.
By providing your e-signature below, and submitting this form, you: 1) are applying for approved supervision with SOUND Life Recovery, 2) confirm that all information provided is true and correct to the best of your knowledge, 3) authorize SOUND Life Recovery to contact you and any references listed above, and 4) agree to communicate via electronic means.
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