Reference Form - Therapy North

Reference Form: Therapy Training Application

Applicant Name *

Referee Name *

Relationship to Applicant *

How long have you known the Applicant? *

1. Suitability Assessment

Please rate the applicant on the following core competencies:

Academic/intellectual potential *StrongAdequateConcerns

Emotional Resilience & Stability *StrongAdequateConcerns

Integrity & Ethical Boundaries *StrongAdequateConcerns

Ability to Accept Feedback *StrongAdequateConcerns

2. Written Comments

A. Strengths: Briefly describe why you think this applicant is suitable for professional therapy training *e.g. their empathy, listening skills or academic ability

B. Areas for Development / Concerns: Do you have any concerns regarding their emotional robustness, honesty or ability to manage stress? *

3. Safety & Ethics

Do you know of any reason why this applicant should not work with vulnerable people? *No - I have no concernsYes

If Yes, please explain:

4. Recommendation

Please select one: *Highly Recommend: They are ready for trainingRecommend with reservations: They have potential but require supportDo not Recommend: They are not ready at this time

Signature *Type name

Your Email Address *We will send a copy of this reference to verify you were the sender

Date *