Reference Questionnaire

I hereby give permission to complete the following reference request furnished by Youth Encouragement Services, Inc. I understand that this information will become part of an application and is considered CONFIDENTIAL and will not be revealed to me. Please complete and submit to the YES Home.

Potential Hire First Name *

Potential Hire Last Name *

Reference First Name *

Reference Last Name *

Phone Number *

Email Address *

Organization *

Title *

Relationship to you *

Number of years known *

In what capacity did you know the applicant at the time? *

In if the applicant were applying to you for a similar position, would you employ? *

Do you feel this person is able to provide a safe and healthy environment to persons being served by the YES Home? Yes or No and please explain: *

Please indicate by check mark in appropriate columns your confidential rating of the applicant *

	Unsatisfactory	Below Expectations	Satisfactory	Exceeds Expectations	Clearly Outstanding	Lack Basis for Evaluation
General personality	Unsatisfactory	Below Expectations	Satisfactory	Exceeds Expectations	Clearly Outstanding	Lack Basis for Evaluation
Adaptability to new ideas	Unsatisfactory	Below Expectations	Satisfactory	Exceeds Expectations	Clearly Outstanding	Lack Basis for Evaluation
Rapport with staff	Unsatisfactory	Below Expectations	Satisfactory	Exceeds Expectations	Clearly Outstanding	Lack Basis for Evaluation
Rapport with consumers	Unsatisfactory	Below Expectations	Satisfactory	Exceeds Expectations	Clearly Outstanding	Lack Basis for Evaluation
Attitude towards supervision	Unsatisfactory	Below Expectations	Satisfactory	Exceeds Expectations	Clearly Outstanding	Lack Basis for Evaluation
Follows established procedures	Unsatisfactory	Below Expectations	Satisfactory	Exceeds Expectations	Clearly Outstanding	Lack Basis for Evaluation
General professional competence	Unsatisfactory	Below Expectations	Satisfactory	Exceeds Expectations	Clearly Outstanding	Lack Basis for Evaluation
Dependable	Unsatisfactory	Below Expectations	Satisfactory	Exceeds Expectations	Clearly Outstanding	Lack Basis for Evaluation

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