Professional/Colleague Reference Form

APPLICANT"S NAME:

The person named above has applied to the Professional Association of Christian Counsellors and Psychotherapists (PACCP) to become a member. Your assessment of the applicant"s characteristics will enable PACCP to evaluate whether this applicant meets its standards. Please respond to all questions to the best of your ability.

REFERENCE"S NAME

POSITION TITLE and PROFESSION:

Degree:

HOW MANY YEARS HAVE YOU BEEN IN CLINICAL PRACTICE?

TELEPHONE:

EMAIL:

Is there any reason that you should not be considered an appropriate reference (e.g., conflict of interest, lack of knowledge of applicants clinical work as a counsellor, etc.)?

YesNoOther

Do you have an association with the applicant other than that of supervisor/colleague?

NoYesOther

How long have you known the applicant?

In what capacity do you know the applicant?

Do you have any concerns regarding the competency or integrity of character of this applicant?

Please rate the applicant compared to other counsellors you know on the following characteristics. Please place a check mark in every category.

Rows	Outstanding	Above average	Average	Below Average	Cannot Evaluate
Individual/Couple/Family Counselling
Group counselling skills
Personal integrity
Consulting skills
Ability to relate to co-workers
Ability to be objective on the job
Ethical conduct
Concern for welfare of clients
Sense of responsibility
Recognition of own limits
Supervisory abilities
Ability to keep material confidential
Commitment to ongoing professional development

Recommendation: I recommend this applicant for membership with the Professional Association of Christian Counsellors and Psychotherapists (PACCP):

YesNo

Additional Comments:

The above recommendation is based on my best judgement. I am willing to answer additional questions concerning this evaluation is PACCP deems it necessary. Signature of Reference

Date