Member DMG + American Association of Christian Therapists


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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


Use Typewriter or black ink.
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 _______________________________


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


P.O. Box 3634, Brookhaven, MS  39603 U.S.A. 

OFFICE NUMBER: 601-990-4523

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Or call anytime and leave a voicemail.
You may fax your application and all supporting documents