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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

Personal Acquaintance with Applicant

I have known this applicant for:

I have known the applicant in my role as:

Personal Character of Applicant

In terms of the applicant’s ethical and moral character, I would assess his/her behavior and reputation as being:
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):

Relational or Social Style and Potential

I assess the applicant’s style as (check all that apply):

I further assess the applicant’s behavioral attitudes and actions as including the following (check all that apply):

Responsibility & Initiative:


I do not know the applicant well enough to offer an assessment on items:

Religious Faith and Congregational Loyalty

In terms of religious faith commitment and active congregational loyalty / participation, I view the applicant as:

Learning Potential

regarding teachability and learning potential, I view the applicant as:

Your Personal Disposition

If I were in a position to accept this applicant into a clinical pastoral education (CPE) program, I would...

Please enter in MM/DD/YYYY format.

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