Clinical Pastoral Education 6 Clinical Pastoral Education Reference Form

Program applying for:

______ Residency

______ Summer Intensive

CPE Applicant Information Name: Mailing Address: Email Address: Phone Number:	Reference Information Name: Position: Email Address: Phone Number:

Please email form directly to:

Rabbi Shulamit Izen, Director, Clinical Pastoral Education

MGHCPE@MGH.harvard.edu

This form will be kept confidential

1. How long have you known the candidate, and in what capacity?

2. How do you evaluate the candidate:

a. In candidate’s ability to receive feedback about their learning?

b. In candidate’s ability to work as part of an interdisciplinary team?

3. Please evaluate the candidate on the following scale.

Excellent	Very Good	Good	Weak	Very Weak

Written and Verbal Communication
Job Perseverance
Emotional Maturity
Creativity
Self-reflection
Attendance
Dependability
Ability to handle a stressful environment

5. Please elaborate on any of the above.

6. Please include any additional comments or concerns that would help give us insight into the applicant’s ability to function as a CPE student in a Level 1 Trauma hospital.

Reference Signature: ______________________________	Date:____________________________