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Obladc Form 205 Oklahoma Board Of Licensed Alcohol/drug Counselors - Professional Reference Form Page 2

On the basis of your knowledge of the above named counselor, rate his/her abilities in each area listed

You will find seventeen (17) abilities which we would like for you to rate 1,2,3,4,5, or Don’t Know.

Rating of 1 is equivalent to POOR

Rating of 4 is equivalent to GOOD

Rating of 2 is equivalent to FAIR

Rating of 5 is equivalent to EXCELLENT

Rating of 3 is equivalent to ACCEPTABLE

Poor

Excellent

Abilities To Be Evaluated

Don’t Know

Common Sense

Poise

Enthusiasm

Reliability

Personal and Professional Honesty

Empathy

Ability to Work With Others

Ethics

Knowledge of Alcohol Abuse Field

10. Knowledge of Drug Abuse Field

11.

Effectiveness of Counseling Approach & Techniques

12. Appropriateness of Counseling & Techniques

13. Communication Skills

14. Ability to Interact With Other Professionals

15. Assessment Skills

16. Consulting Skills

17. Research Skills

In the space below, you may add information regarding the applicant’s fitness for licensure or certification

heretofore addressed. If you have reservations regarding this applicant’s fitness for licensure or certification,

please do not hesitate to include those concerns.

I hereby certify that this rating is, to the best of my knowledge, truthful and reflects as accurately

as possible my knowledge of the applicant.

_____________________________________________

__________________________________

SIGNATURE

DATE

THE LICENSURE BOARD RESERVES THE RIGHT TO REQUEST FURTHER INFORMATION FROM YOU CONCERNING

THIS APPLICANT.

Return this form to the person requesting it.

OBLADC Form 205

8/2005

Obladc Form 205 Oklahoma Board Of Licensed Alcohol/drug Counselors - Professional Reference Form Page 2