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!

Reference Information

What applicant are you filling out this reference form for?
Were/are you a supervisor to this person?
Please describe
Please describe

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
Actual Clinical Performance:
Performance related to professional obligations:
Professional ethics:
Clinical judgment / technical skills:
Attendance:
Quality of Work:
Communication
Would you recommend this applicant for hire?
Type your name to sign this reference form.
MM slash DD slash YYYY