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Mentor Reference Form

The UCI LGBTQ Mentoring Program is sponsored by the Counseling Center. This program pairs LGBTQ students with more knowledgeable, self-accepting LGBTQ mentors. It strives to help students develop a positive LGBTQ identity.
Applicant's UCI Affiliation?
Who are you writing this recommendation for? 
What is your name?
What is your title/employer?
What is your phone number?
What is your email?
How do you know the applicant? How long have you know the applicant?
Please rate the applicant on scale of 1 (strongly disagree) to 5 (strongly agree) for the following dimensions. 
The
applicant usually fulfills their commitments. They are reliable.

Theapplicant usually fulfills their commitments. They are reliable.

The
applicant can communicate effectively on a
one-on-one basis.

Theapplicant can communicate effectively on aone-on-one basis.

I
believe the applicant would conduct themselves in a professional manner.

Ibelieve the applicant would conduct themselves in a professional manner.

I am confident
that the applicant has good interpersonal boundaries and therefore would not
behave inappropriately with a student.

I am confidentthat the applicant has good interpersonal boundaries and therefore would notbehave inappropriately with a student.
I believe the applicant would be a valuable mentor.
I believe the applicant would be a valuable mentor.
Why would this applicant be a valuable mentor?

Is
there anything else (positive or negative) about the applicant that would
affect their ability to serve as a mentor?

Please sign below. 
Clear

For further information
feel free to contact Dr. Christine Fuston at lgbt.mentors@uci.edu



 



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