ࡱ> uxt \bjbj s|| TR),0t  ) ) ) ) ) ) )$*-/)QU@/)0%)o(o(o(n0 )o( )o(o(o(,|ن@7"o(()0)o(..7" ..o(o(&..(`o(/)/)A%.).. : PERSONAL REFERENCE FORM Counseling Masters Degree Programs Division of Psychology and Counseling  To the applicant: Please complete the top portion of this form and then deliver it to an academic professor or a community professional (supervisor) who is acquainted with your academic program and/or with your professional experience. Contact the advisor if you do not have an academic (faculty) or professional (employer) references. Name of Applicant:  FORMTEXT        FORMTEXT       FORMTEXT    Last First Middle Address: FORMTEXT       Email: FORMTEXT       Master s Degree Program (circle one): Clinical Mental Health Marriage & Family School The Family Educational Rights and Privacy Act of 1974 allows students to inspect their educational records. The law also permits the student to waive his/her right to inspect letters of recommendation. By signing below, you waive your right to read this letter of reference. Signature of Applicant Date To the person completing this form: The person named above is applying for admission to a masters degree program at Governors State University. Please complete this form, place it in an envelope, sign your name across the sealed flap, and return it to the applicant as soon as possible. PLEASE DO NOT LEAVE ANY ANSWERS BLANK OR INDICATE SEE ATTACHED LETTER. Please make sure each answer is answered directly on this form. Please rate the applicant on each of the areas below using the following scale: 5 = outstanding, 4 = very good, 3 = good, 2 = fair, 1 = poor. If you have rated this applicant 2 or below, please explain. 54321N/AAbility to accept criticism  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Ability to be flexible in thinking  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Ability to express ideas clearly  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Ability to interact with people  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Ability to adapt to new ideas  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Ability to engage in self-exploration  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Ability to maintain academic/ professional commitment  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  1. How long have you known the applicant and in what capacity?  FORMTEXT       2. What are the principle strengths of the applicant?  FORMTEXT       3. What are the primary growth areas of the applicant?  FORMTEXT       4. 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Additional Comments:  FORMTEXT       Signature Date UUUUUUUV\\&\(\<\>\@\J\L\N\P\b\d\x\z\|\\\\ʼӸʪj!h5h5Uh5ji!h5h5U h5h5U h]">*h]" h5h]" jh5h5UmHnHujh5h5UUUUUU\\N\P\\ hd' hd6$ Position/title:  FORMTEXT       Address:  FORMTEXT       /0/ =!8"8#8$8% n( 8\ILm45PNG  IHDRo*bKGD#2 cmPPJCmp0712`PIDATx^;xgfge7=4 $ E@M@ PtPDJ t4)ll/ l|{rڽP7FLH͌T,j&[3#=t԰fFi`ጸvsA4/\Z KK{0]3ON 7ͮ}wY=(PTpU@hJp' * K^ܺgkZRuËmP%@܆:t7swf'Dg0Cav{M {D\[1'RV'F9[-?΍Q?{ƌhƪPV9 R)܅ Ek;V[q&t |kf,CZ6h.dhe~ܟ]4b뀷igޯ5.d =f9^ԻTl Y:n?Щ1` & 5<<܏E<ڢ5ko-1]wUr%yFpXHHq+&o{l$7Ԧƒ̙[:xA6{Ppߍ-`qO0.再NKOwvٛk?0ܾC?c vSK[ Wڌoldž(xzY3nb}Ar<LfܴG!H"4X3IM׬b݆AC̟w or6?AkW7_ Vv4:1h.EM_Qd %pHWt F,| /B]-_aęQNk.Q\HO2yY: TᐏOPr,\;ўbOEx]PZޖRGSpˊ9i:bN?tצkM&#@ @7+E&֊h(jcMr"5~:UxG*qaGE=(y) /ypUުEh)gic-+笠Q~],0[S? )NXa!a_UB`ӹ\悥QvD{phA^B "AwAX49H]OȃuhKv+~5ad*L1h |~?TQ0G#}Ǖ-TViY-԰Yot[ϼGii*[b W#3Ju\=ͽn_0^|iYtiQn5p[R~]'D/LΘ=UO/B?  9#j[[RN9K&&Kutea*)c,Ach`ԩ*ZU ֖+cTrZW_) EZ_PEΕՉ+PBb]W>L=|hIbH~ҁ6 JĒe1tPAtAFdnZ,-M^x\-+|%{^򋂭w|#ZXQ$1y &?!|Z7,Ec(/j.ԙ>o"jޓL{Y'zX: 2(SǺTO ;vC, 4XmM% ^pMp9BP{F B BY˵s~tYϸm24KY[jaxP *| KRL!f3N5GoTUFi?2N%SfBɿn? qFb<:J,9~k=:3UhkV$S똾}loG{HƢ~5ۛ/;amj/9|S= u|/͛:"tY氩Gj~^fϑ%'$Eun3 CaIi~moXu:vQ+0,o c2t> Hc83<\ZWž7){NR> "5Y(GqS$csj<]4> W? 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