Court Appointed Special Advocates (CASA) of Pulaski County

Personal Reference

Name of Referrence --- Please put the name of the person you are completing the reference on. (ALL Information in this form will be held confidential in every respcet):

Volunteer Court Appointed Special Advocates conduct independent investigations to assess appropriate placement options and services to be provided for abused and neglected children. They submit written court reports and testify in court regarding their recommnedations. With that knowleddge please respond to the following questions as truthful as possible. -------- How Long have you known the applicant?:

What is your relationship to the applicant?:

Do you have knowledge of how the applicant related to children?:

• Yes
• No

If yes, please explain below:

Can the applicant separate their personal life from their advocate work experience? :

Can the applicant maintian objectivity when dealing with issues of child abuse and substance abuse?:

Do you know any reason why this person might not be a reliable CASA volunteer advocate?:

Please respond to the following statement based on a scale of 1-10 with 10 being strongly agree and 1 being strongly disagree --------- Applicant has a flexible schedule:

Applicant has good communication skills:

Applicant has good writing skills:

Applicant is self-motivted:

Applicant is calm under stress:

Check all of the characteristics that describe the applicant:

• Domineering
• Tactful
• Considerate
• Stubborn
• Reserved
• Nervous
• Leader
• Moody
• Confident
• Opinionated
• Friendly
• Happy
• Arrogant
• Follower
• Adjusted
• Assertive
• Aggressive
• Unhappy
• Lacks Confidence
• Cooperative

Would the applicant have problems in working with any of the following persons? (check all that apply):

• Females
• Males
• Abusive Parents
• Drug addicts
• Minorities
• Handicapped
• Various religious preferences

Please explain any checked answers:

How well does the applicant finish projects and activities begun?:

• Very well
• Well
• Average
• Fair
• Poor

To your knowledge has this applicant ever had an alcohol dependency or substance abuse problem?:

• Yes
• No

If you answered yes, please explain below:

Would you be comfortable having the applicant serve as a Court Appointed Special Advocte to a child?:

• Yes
• No

If you answered no, please explain:

Please use this next section to discuss any additional information you want to share with us regarding this applicant. Your comments are extremely important in our decision to accept or decline the applicant as a CASA advocate.:

By typing your name below it will be an official signature. Please type your name below.:

Todays Date:

ex. mm/dd/yyyy