Name of applicant

Mr. Mrs. Miss Ms. Name: Surname:

Your name

Mr. Mrs. Miss Ms. Name: Surname:

Training course the applicant is applying for:

Introduction to Community Counselling Certificate in Community Counselling Diploma in Community Counselling

In order for us to verify the authenticity of this reference, it is possible we will contact you:

Present Address:

Post Code: Country:

Mobile Phone: Home Phone:

Work Phone: Fax Number:

Email Address:

Your Position:

Pastor / Spiritual Leader Friend YWAM School Leader

Not at all A little Quite well Very well

No Yes

5 = Very Good, 1 = Very Poor, 0 = Not Observed

Communication Skills 1 2 3 4 5 0

Openness and humility 1 2 3 4 5 0

Stability 1 2 3 4 5 0

Self esteem 1 2 3 4 5 0

Spiritual maturity 1 2 3 4 5 0

Ability to cope with stress 1 2 3 4 5 0

Concern for others 1 2 3 4 5 0

Academic ability 1 2 3 4 5 0

Working in teams 1 2 3 4 5 0

Reliability 1 2 3 4 5 0

Demonstrates initiative 1 2 3 4 5 0

Ability to handle conflict 1 2 3 4 5 0

No With hesitation Yes, moderately Yes, strongly