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Send a Reference

Someone you know has recently applied to work with Portage Path Behavioral Health. Please fill out the form below and send it to us. Your reference is needed to complete the candidate’s application. Thank you!

Step 1 of 3

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Reference Information

What applicant are you filling out this reference form for?

First Name Last Name

What position is the applicant applying for?

How long have you known the applicant?

In what capacity have you known this person?

Were/are you a supervisor to this person?

Yes

No

If yes, what position did they hold?

Dates of Employment (Start and End)

If You Knew the Applicant in a Clinical Setting Please Complete the Following

If applicable please complete if not please continue to next page.

Nature of actual clinical duties:

Please describe

Clinical populations treated/managed:

Please describe

All References Please Complete the Following

How would you rate the applicant in the following areas? Please select the appropriate number.

1 = Outstanding
2 = Good
3 = Average
4 = Needs Improvement
5 = Unsatisfactory

Performance related to professional obligations:

1 - Outstanding

2 - Good

3 - Average

4 - Needs Improvement

5 - Unsatisfactory

Professional ethics:

1 - Outstanding

2 - Good

3 - Average

4 - Needs Improvement

5 - Unsatisfactory

Judgment / technical skills:

1 - Outstanding

2 - Good

3 - Average

4 - Needs Improvement

5 - Unsatisfactory

Attendance:

1 - Outstanding

2 - Good

3 - Average

4 - Needs Improvement

5 - Unsatisfactory

Quality of Work:

1 - Outstanding

2 - Good

3 - Average

4 - Needs Improvement

5 - Unsatisfactory

Communication

1 - Outstanding

2 - Good

3 - Average

4 - Needs Improvement

5 - Unsatisfactory

Would you recommend this applicant for hire?

Yes

No

Why?

Name

Type your name to sign this reference form.

Title

Date

MM slash DD slash YYYY

Company Name

Your Email

Your Phone Number

Δ

340 South Broadway Street
Akron, Ohio 44308
330-253-3100

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© 2025 Portage Path Behavioral Health. All rights reserved. | Privacy Policy | Employee Portal

Please choose your Portage Path provider from the drop down menu at the time of your scheduled appointment ONLY.

Please call 330-253-3100 to reschedule or change your appointment to telehealth.

If you are in crisis, please call 988 or visit Psychiatric Emergency Services at 10 Penfield Road, Akron.

Proceed to Telehealth