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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 to:
Fax:
See AACT Home Page
REFERENCE FORM
Use Typewriter or black ink.
Waiver:
I waive the right to review reference responses to this form.
Therapists or Ministers Signature
_________________________________________________________________________
To the Reference: The person listed below has given your name as a reference. Please complete this form and return
to AACT 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: AACT
Dr. Gary Barkman, President
P.O. Box 3634
Brookhaven, MS 39603
Ministers/Therapists Name
_______________________________________________
Address _______________________________________________
Address
2 _______________________________________________
Phone / Email __________________/____________________________
Reference
Name _______________________________________________
Address _______________________________________________
Address
2 _______________________________________________
Phone / Email __________________/____________________________
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 _______________________________
PERSONAL CHARACTERISTICS
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 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
PRINT TWO (2) COPIES AND GIVE TO YOUR
REFERENCES
HAVE THEM SEND THE FORM DIRECTLY TO AACT
AACT
P.O. Box 3634, Brookhaven,
MS 39603 U.S.A.
OFFICE NUMBER: 601-990-4523
Ask our receptionists for
a catalog or packet ...
Call between 9 AM & 5 PM
Monday Through Friday...
Or call anytime and leave a voicemail.
You may fax your application
and all supporting documents
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