Applicant's Name:___________________________ Date:______________

To:________________________________________________________
(Reference Name)

Address: ____________________________________________________
(Reference Address)

Home phone :____________________ Work phone: _________________
(Reference Phone)

I agree that the information supplied by the person named above shall remain in confidence. I waive my rights to see this information.

Signed:_________________________________ Date:_______________
(Candidate Signature)

The individual named above is applying for admission to the Masters Program. In an effort to assist us in both maintaining the highest standards of professionalism and to plan individual learning contracts, we would appreciate you being candid and specific.

How long have you know the candidate?______________________________

In what capacity? ______________________________________________

Please rate each of the following:

	Excellent	Moderate	Minimal	Don't Know
1.Conceptual ability	________	________	________	________
2.Writing ability	________	________	________	________
3.Speaking ability	________	________	________	________
4.Ability to accept criticism	________	________	________	________
5.Ability to be autonomous	________	________	________	________
6.Self-awareness	________	________	________	________
7.Ego strength	________	________	________	________
8.Personal boundaries	________	________	________	________
9.Flexibility	________	________	________	________
10.Stability	________	________	________	________

What do you imagine will give this potential marriage and family therapist the most difficulty?

With what will the candidate have the least difficulty?

Assuming the candidate had therapeutic skills, would you be likely to refer a relative to him/her?

Yes___ No___

Would you recommend that this candidate be in personal therapy as a part of his/her training?

Yes___ No___

Additional comments:

Signed:________________________________ Date:________________

"The confidentiality of this record is required under Chapter 306 of the Connecticut General Statutes. This material should not be transmitted to anyone without written consent or other authorization as provided in the aforementioned statutes."

"The views and opinions expressed in this page are strictly those of the page author and have not been reviewed or approved by the University."