Professional Reference

INSTRUCTIONS:  Please download as word document, complete questions, save and email to connect@twelve12:Hope.org by April 15th, 2019.

To the applicant:

Please include your name below as indication that you agree to this waiver. Request the person filling out this reference to complete the form and email it directly to Twelve12:Hope at connect@twelve12hope.org .

        

Applicant name:              

To the person filling out this reference:

The above named person is completing an application to join a child trauma training program for Twelve12:Hope involving training and practical field experience.

Your name:                                          Address:

Phone:                         

Position:                                    Agency:

Date:  

In what capacity do you know this person? For how long?

What opportunity for observation have you had of this person’s professional, and over what period of time?

Please rate this person by checking the number as it applies under each of the following headings. If possible, please make additional comments to support, explain, or add to your evaluation.  

                                                               Deficient       Below Peer       Peer Level  Above Peer     Excellent      

                                                                                                Level                                        Level                                    

Interpersonal Skills

1

          2

           3

          4                

       5

NA

Is warm and approachable

         

          

         

Easily engages in conversations

         

          

          

Is non-defensive, willing to be vulnerable

         

          

         

Genuinely respects and likes people

         

          

         

Has natural giftedness in helping skills        

         

          

         

Shows discretion in speech        

         

          

         

Shows appropriate affect

         

          

         

Additional comments      

                               

Professional  Skills

1

            2

3

4

5

NA

If married, spouse supports this career

        

Is able to maintain confidentiality        

        

Spouse is able to maintain confidentiality

        

Is insightful and discerning

        

Has ego strength to confront when needed

        

Is able to cope with stress

        

Handles transitions well        

        

Establishes appropriate boundaries

        

Is able to offer help without taking responsibility for others        

      

Additional comments      

Teaching skills

1

          2                 

         3

           4

         5

NA

Is able to teach with skill

         

        

          

Able to engage attendees in discussion

         

        

          

Shows skill in giving

        demonstrations/role-plays

         

        

          

        

     

Additional comments      

Case Management Skills

1

2

3

4

5

NA

Follows policies and procedures of

the ministry

Cooperative with staff

Manages work load        

Professional ethics

Understands legal issues

Additional comments      

 

Supervision

    1

2

         3

           4

          5

NA

Makes good use of supervision

   

        

          

         

Evaluates own performance        

   

        

         

Accepts feedback from peers and supervisors

   

        

          

Raises questions

   

        

          

Reports problems

   

        

          

         

Incorporates suggestions

    

        

          

Keeps case notes & treatment plans up-to-date

   

        

          

Additional comments  

   

Professional engagement

1

2

3

4

5

NA

Ability to be genuine

Demonstrates good listening skills

Ability to develop & maintain good working

relations      

Empathic ability

Ability to be concrete in giving feedback

Additional comments      

Observation and diagnostic skills

1

2

3

4

5

NA

Interview and Assessment skills

Ability to formulate and set goals

Recognizes limitations and strengths of

clients

Integrates theory and practice

Evaluates outcome of time spent with client

Additional comments      

Professional intervention

1

2

3

4

5

NA

Plans intervention

Capacity to explain and evaluate outcomes of

        proposed interventions                

Able to engage with parent about child issues

Mobilizes resources (internal & external)

as needed

Selects alternate interventions when needed

Additional comments      

If you needed professional intervention for your children, would you go to this person in a professional context? Why or why not?  

     

Please add any comments that would help us know this person’s fitness for involvement in this child trauma program.


Do you recommend this person for the child trauma training program?                                

         Yes

         Yes, but with some reservation as suggested by the above comments.

         No, but could become acceptable with growth in areas mentioned above.

         No, I cannot recommend this person.