Clinical Supervisor
Reference Form
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.
APPLICANT"S NAME:
*
REFERENCE'S NAME
*
POSITION TITLE and PROFESSION:
Degree:
Please Select
Masters
Doctorate
Other
In what capacity do you know the applicant? (ie. supervisor, colleague, friend, pastor)
TELEPHONE:
EMAIL:
example@example.com
Is there any reason that you should not be considered an appropriate reference (e.g., conflict of interest, lack of knowledge of applicants character or abilities as a counsellor)
Yes
No
If yes, explain:
Do you have an association with the applicant other than that of supervisor/colleague?
No
Yes
If yes, explain:
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?
FOR SUPERVISORY REFERENCES: 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
How many hours of supervision did the applicant have with you?
Recommendation: I recommend this applicant for membership with the Professional Association of Christian Counsellors and Psychotherapists (PACCP):
Yes
No
Additional Comments/Concerns about Character and Integrity:
The above recommendation is based on my best judgement. I am willing to answer additional questions concerning this evaluation is PACCP deems it necessary. Signed by Name of Reference
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: