Reference Form Comments Recovery Week Reference Form2019-09-09 GL Fixed form error. Removed this code from the first field's (Open Fixed) calculation: replaceAll('<br>','\n\n',open) Calculations - Do Not Change Parameters The following fields are pre-populated from SalesForce based on the value of i based in the URL Recommendation RecievedPlease select... Yes No Waived right to reviewYesNo Please describe the nature of your relationship with this applicant (i.e., therapist/counselor, pastor, lay counselor, recovery group leader, etc) How long have you know the applicant and what is the frequency of your work together? Are you a licensed, professional counselor/therapist?YesNo What is your clinical diagnosis? (Please provide DSM-5 diagnostic codes) In one to three words, describe the applicant’s presence. Describe the applicant’s capacity for self-reflection. Describe the applicant’s awareness of her/himself in relation to others. What patterns or behaviors have you noticed when the applicant is triggered/flooded/defended? In one to three words, describe the role you would imagine this applicant playing in a group? What concerns, if any, do you have about this applicant’s participation in an offering of this nature? Please use the space below to provide any additional comments that you feel will be helpful in considering this applicant for admission. Do you recommend the applicant for admission a Recovery Week at The Allender Center?Please select... Highly Recommend Recommend Recommend with Reservation Do not Recommend Please Explain the reservations you have with this applicant. Reference Information First Name Last Name Organization Title City State Postal Code Phone Professional License Number State of Licensure Please type your full name, understanding that it is legally equivalent to your signature and constitutes your certification that your assessment is accurate and fair to the best of your knowledge. The recommendation has already been submitted. Thank you for offering your words and perspective on the applicant. If you believe this submission was in error, please contact recoveryweeks@theallendercenter.org Need assistance with this form?
