Reference Name:              

Reference Telephone:       

Applicant (Mentor) Name:       

Please select the following assessments ("excellent", "good", "fair", or "poor") based upon your knowledge of an experience with the above named applicant.

1. Applicant's ability to manage his/her emotions.               Excellent Good Fair Poor

2. Applicant's ability to manage stress:                               Excellent Good Fair Poor    

3. Applicant's personal ethics:                                            Excellent Good Fair Poor     

4. Applicant's stability/maturity:                                          Excellent Good Fair Poor  

5. Applicant's ability to accept responsibility:                      Excellent Good Fair Poor    

6. Applicant's general appearance:                                     Excellent Good Fair Poor   

7. Applicant's judgment demonstrated in their daily life:       Excellent Good Fair Poor

8. Stability and harmony of applicant's family life:                Excellent Good Fair Poor     

9. Applicant's ability to relate to and understand children:    Excellent Good Fair Poor

10. Applicant's ability to accept others as the way they are: Excellent Good Fair Poor

11. How well do you know the applicant?                          Very Well Well Average Little Very Little

12. Would you consider placing the responsibility of your own child with the applicant? Yes No

      Why or Why Not?   

13. Do you have any additional comments?