Candidate First Name *
Candidate Last Name *
Candidate Phone *
Reference First Name *
Reference Last Name *
Reference Phone *
Reference Employer *
Reference Title *
Reference Completed By *
Date Completed *
How long have you known the candidate? *
How do you know him/her? *
Current SupervisorFormer SupervisorCurrent Co-WorkderFormer Co-WorkerOther
Employment Dates *
What position did he/she have in your organization? *
Give me a brief description of his/her job duties and responsibilities. *
What are three things he/she does best (Strengths)? *
If you believe, as we do, that everyone can improve in certain aspects of their job performance, in what ways can he/she improve their performance over the next five years (Weaknesses)? *
How did he/she perform as a team member? *
How much direction did he/she require from you? *
How did he/she respond to organization or job changes? *
Do you have any reason to question his/her honesty or ethics? *
Do you have any reason to think this person would be a danger to a mental health client? *
Please rate the candidate's performance in the following categories:
Attendance
PoorFairGoodExcellentN/A
Reliability
Attitude
Cooperation
Clinical / Work Related Skills
Verbal Communication Skills
Written Communication Skills
Overall Job Performance
Would you work with him/her again? *
If you were to describe this candidate in 25 words or less to an employer, how would you describe them as an employee? *
Is there anything we have not discussed concerning this candidate that you think is important or would like to add? *
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