Member DMG + American Association of Christian Therapists

Reference Form

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Print two copies of this form and give to two persons who will recommend you

          You may fax this signed reference form


Use Typewriter or black ink.




I, ________________________________ (applicant) hereby waive the right to review reference responses to this form.


Applicant’s Signature (required).




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.


Please mail this form to:


          P.O. BOX 143

          Tolar, TX 76476


Reference Ministers/Therapists Name ______________________________________


Address _____________________________________________________________


City: _________________________ State: _____  Zip Code: __________________


Phone / E-mail __________________/____________________________


How Long have you known this person: __________________________


Relationship:           ___ Lay member of present congregation

                    ___ Lay member of previous congregation

                    ___ Clergy Colleague

                    ___ Counselor / Therapist Colleague

                    ___ Fellowship / Denominational Leader / staff

                    ___ Family Friend


                    ___ Other _______________________________



Please place the appropriate number in the blank following the personal characteristic:


1 Exemplary 2 Many Times 3 Seldom 4 Do Not Know


_____   1   Follows through with responsibilities

_____   2   Protects confidentially

_____   3   Handles pressure well

_____   4   Manages time wisely

_____   5   Appropriate personal appearance

_____   6   Likes people

_____   7   Handles conflict well

_____   8   Portrays Christian maturity

_____   9   Takes criticism well

_____   10   Takes praise graciously

_____   11   Seeks help from others when needed

_____   12   Takes time for study

_____   13   Is creative/imaginative

_____   14   Has a positive attitude

_____   15   Is flexible/adaptable

_____   16   Is a good listener


This 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


For what type of situation do you feel this person best suited?



Are there counseling or ministerial situations for which it would be unwise to consider him/her?



In this persons counseling, does he/she maintain confidentiality; being compassionate and sensitive to others needs; helping persons develop emotional maturity and security?



In 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 situations?




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)



Signature ______________________________________  Date _________________


This form is provided by the American Association of Christian Therapists, Granbury, Texas, 2002







P.O. Box 143

Tolar, TX 76476 U.S.A.


OFFICE NUMBER: 817-736-3041


or  Dr. Barkman's Cell:  817-219-7007



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