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CPE Reference Form
CPE Reference Form
Spiritual Care Applicant Character Reference Form
Please check your answers of assessment for each line or statement given in this form. You may make additional comments at the end of the form if you wish to do so.
Applicant Character Reference Form
Name of Applicant:
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Personal Acquaintance with Applicant
I have known this applicant for:
less than one year
one to four years
five years or more
I have known the applicant in my role as:
pastor, priest, rabbi, or other religious leader
teacher or professor
employer
confidante and/or friend
other
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Personal Character of Applicant
In terms of the applicant’s ethical and moral character, I would assess his/her behavior and reputation as being:
outstanding
above average
average
deficient
unknown to me
Are you aware of any present or past information that might suggest potential problems of which we may need to be aware? (Check all that apply):
gender
religious tradition
culture
authority
none
Other
Relational or Social Style and Potential
I assess the applicant’s style as (check all that apply):
very warm, friendly, and outgoing
friendly and outgoing
somewhat warm, friendly, and outgoing
somewhat stiff and/or hesitant in interpersonal relationships
having difficulty with males in relationships
having difficulty with females in relationships
having difficulty with same-sex relationships
having difficulty with relating to persons of lesser authority
having difficulty with relating to persons of greater authority that s/he holds
having difficulty relating to persons of other cultures
having difficulty relating to persons of other faith traditions
noticeably deficient in social graces and skills
unknown to me
I further assess the applicant’s behavioral attitudes and actions as including the following (check all that apply):
Dependability:
very dependable and trustworthy
deficient in dependability
Responsibility & Initiative:
always takes appropriate initiative in carrying out tasks and responsibilities
usually takes appropriate initiative in carrying out tasks and responsibilities
sometimes takes appropriate initiative in carrying out tasks and responsibilities
shows deficiencies in carrying out tasks and responsibilities
Cooperativeness:
very cooperative in group discussions and group tasks
somewhat cooperative in group discussions and group tasks
has a tendency to dominate or control group projects
has a tendency to withdraw or give minimal input in group efforts
I do not know the applicant well enough to offer an assessment on items:
dependability
responsibility and initiative
cooperativeness
Religious Faith and Congregational Loyalty
In terms of religious faith commitment and active congregational loyalty / participation, I view the applicant as:
outstanding
above average
average
showing difficulty or deficiency
unknown to me
Learning Potential
regarding teachability and learning potential, I view the applicant as:
outstanding
above average
average
showing difficulty or deficiency
unknown to me
Your Personal Disposition
If I were in a position to accept this applicant into a clinical pastoral education (CPE) program, I would...
do so quickly and without hesitation.
choose to look for applicants with greater potential.
choose to look for applicants with more attractive qualities.
be skeptical or tentative.
deny the applicant’s request.”
Added Comments (optional):
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Electronic Signature (type full name):
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Position:
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Date:
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Please enter in MM/DD/YYYY format.
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Email
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