CPE 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:

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

Personal Character of Applicant

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

outstandingabove averageaveragedeficientunknown 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 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:

outstandingabove averageaverageshowing difficulty or deficiencyunknown to me

Learning Potential

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

outstandingabove averageaverageshowing difficulty or deficiencyunknown 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):

Electronic Signature (type full name):

Date:

Please enter in MM/DD/YYYY format.

Spiritual Care Applicant Character Reference Form