Reference Letter Form

Your candid and accurate evaluation is appreciated.

Applicant Name:
Your Name (Evaluator):
Highest Degree Earned:
Address:
City:
State:
Telephone:
Email:
Business/Institution:
Position:
Recommendation
I have known the applicant for: Years Months
To what extent do you know the applicant? Slightly        Fairly well        Very well
In what capacity do you know the applicant? Student        Advisee        Employee
  Other
Please rate the applicant's potential for work in field of mental health.
Excellent        Good        Average        Below Average        No basis for judgment

Comments:
Emotional Readiness to begin work in the mental health field:
Above Average        Average        Below Average        Unsatisfactory

Comments:
Integrity of candidate (moral, reliability [dependability], ego):
Above Average        Average        Below Average        Unsatisfactory

Comments:
Self-awareness of candidate (insight, appropriateness of defenses):
Above Average        Average        Below Average        Unsatisfactory

Comments:
Tolerance of ambiguity:
Above Average        Average        Below Average        Unsatisfactory

Comments:
Ability to manage stress:
Above Average        Average        Below Average        Unsatisfactory

Comments:
Appropriately motivated toward success:
Above Average        Average        Below Average        Unsatisfactory

Comments:
Intellectual curiosity:
Above Average        Average        Below Average        Unsatisfactory

Comments:
Appropriate values and beliefs relevant to work in the mental health field:
Above Average        Average        Below Average        Unsatisfactory

Comments:
If you are or were associated with a graduate program, would you accept the applicant into your program?
Definitely        Probably        Probably not        Would not        No basis for judgment

Comments:
Indicate the strength of your overall endorsement of the Applicant:
Highly recommended     Recommended     Recommended with some reservation    
 Not recommended
Evaluator Signature:
Date: