Reference Form

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Referee's Name

First

Last

Referee's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Referee's Occupation

Referee's Email

Referee's Phone Number

Applicant Student Name (as per passport)

First

Last

Course For Which Applicant Has Applied

The applicant student named above has applied for a place on a Cork Counselling Services Training Institute course. They have named you as a Referee to support their application. In order that we can assess the applicant’s suitability we would appreciate if you would fill out the following questionnaire. If you have any questions or concerns about any matter, please feel free to contact Ms Karen Walsh, Head Of Training on 021-4274951

1. The capacity in which you know the applicant

2. The number of years you know the applicant

3. The applicant's self awareness and ability to create working relationships

4. The applicant's qualities relevant to working with vulnerable people

5. The applicant's strengths and weaknesses

6. The applicant's capacity to deal with academic demands of a degree course

7. The applicant's communication skills (including written)

8. The applicant's ability to maintain confidentiality

9. The applicant's maturity and ability to be responsible and self-directing

10. Any other comments which you feel are relevant to the application

Signature Of Referee

Clear Signature

Reference Form

Where ordinary

people can make

an extraordinary

difference.

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Part Funded by:

Reference Form

Where ordinary people can make an extraordinary difference. Part Funded by:

Part Funded by:

Where ordinary

people can make

an extraordinary

difference.

Part Funded by: