two copies of this form and give to two persons who will recommend you
may fax this signed reference form
Typewriter or black ink.
I, ________________________________ (applicant) hereby waive the right to review reference responses to this
To the Reference: The person identified above has given your name as a reference. Please complete this form
and return to AFS FAMILY SKILLS INSTITUTE within TWO WEEKS. Neatness, clarity and dark copy which will reproduce well are
essential. If the waiver has been signed the information you put on the form will be kept in confidence, but will be seen
by the Board of Directors of AACT. Thank you for your assistance.
mail this form to:
AACT - AFS FAMILY SKILLS INSTITUTE
P.O. BOX 143
Tolar, TX 76476
Ministers/Therapists Name ______________________________________
_________________________ State: _____ Zip Code: __________________
/ E-mail __________________/____________________________
Long have you known this person: __________________________
___ Lay member of present congregation
___ Lay member of previous congregation
___ Clergy Colleague
___ Counselor / Therapist Colleague
___ Fellowship / Denominational Leader / staff
___ Family Friend
___ Other _______________________________
place the appropriate number in the blank following the personal characteristic:
Exemplary 2 Many Times 3 Seldom 4 Do Not Know
Follows through with responsibilities
Handles pressure well
Manages time wisely
Appropriate personal appearance
Handles conflict well
Portrays Christian maturity
Takes criticism well
Takes praise graciously
Seeks help from others when needed
Takes time for study
Has a positive attitude
Is a good listener
person uses the following leadership style (Rank 1, 2, 3)
Takes primary initiative and responsibility
Allows laity or associates to take primary responsibility
Shares responsibility with laity or associates
what type of situation do you feel this person best suited?
there counseling or ministerial situations for which it would be unwise to consider him/her?
this persons counseling, does he/she maintain confidentiality; being compassionate and sensitive to others needs; helping
persons develop emotional maturity and security?
this persons counseling, does he/she help persons develop their spiritual life; encouraging persons to relate their faith
to their daily lives?
In this persons counseling, does he/she make calls on persons in hospitals; ministering to persons in crisis
Are there other comments which would assist AFS Family Skills Institute and the American Association of Christian
Therapists in making a decision to certify or not certify this person? (Please limit your comments to this and one other page)
______________________________________ Date _________________
form is provided by the American Association of Christian Therapists, Granbury, Texas, 2002
TWO (2) COPIES AND GIVE TO YOUR REFERENCES
THEM SEND THE FORM DIRECTLY TO AACT
TX 76476 U.S.A.
Dr. Barkman's Cell: 817-219-7007
our receptionists for a catalog or packet ...
between 9 AM & 5 PM Monday Through Friday...
call anytime and leave a voice-mail.
may fax your application and all supporting documents
E-mail: email@example.com or: