Internship Reference Form — anomaly therapy

Clinical Mental Health Internship Reference Form

Anomaly Therapy is a boutique private practice in Nashville that provides therapy to individuals and couples. Please complete this personal reference form as thoughtfully as possible. Your comments will help our program serve our clients more effectively and will be considered confidential. Please email Jessica Mansell at jess@anomalytherapy.com or call (615)-988-1158 with any questions!

Applicant Information

Name

First Name

Last Name

Reference Information

Name

First Name

Last Name

Phone

(###)

###

####

Relationship to Applicant

Organization

Applicant Skill Assessment

Please select the number in the scale ranging from high (5) to low (1) which reflects your opinion of the applicant

Ability to relate to adults

Ability to actively listen

Ability to communicate respectfully and effectively

Ability to acknowledge and control emotions

Ability to demonstrate good judgments in daily relations

Propensity to follow through on commitments

Is reliable, consistent, and motivated

Ability to accept responsibility

Stability/harmony of applicant's own life

Applicant & Reference Background

In what capacity have you known this applicant? For how long?

The applicant will work with adult clients (18+) who struggle with mental and emotional pain and discomfort for various reasons. Some have experienced intense trauma and some are seeking relational help. How has this applicant demonstrated stability and strength of character which would support their abilities to perform known job functions and expectations (clinician counseling, documentation, and consultation)?

How has this applicant demonstrated responsibility and dependability that would reassure a client under stress and overwhelm?

Are you aware of any issues that would prevent the applicant from serving as an effective intern with Anomaly Therapy?

Yes

To your knowledge, does this applicant have or has she/he ever had a drinking problem? Drug usage?

Yes

To your knowledge, has the applicant ever been convicted of an ethical violation or a felony?

Yes

If you know this applicant in a professional capacity, would you be inclined to work with this person again?

Yes

Please explain, in your opinion, why the applicant’s personal and professional qualities would be an asset to the Anomaly Therapy team.

Please select your overall assessment of the applicant's suitability as an Intern for Anomaly Therapy

Please feel free to make other comments that you feel may be helpful or relevant

Clinical Mental Health Internship Reference Form

a n o m a l y t h e r a p y