Referrals Assessment

Required Fields *

Name*

Email*

Mailing Address*

City*

State

Zip Code

Country*


Assessment Questions:




1. How do you make assessments about the level of healthy functioning that is within the range which you are trained to work with?*


2. Name eight characteristics and behaviors that are touchstones for health.*


3. Explain how the power differential increases the complexity and/or possibility for misunderstandings to occur.*


Feedback




1. Please rate in terms of value: 1 (lowest) …………… 5 (highest)

Professional:  1 2 3 4 5
Personal:  1 2 3 4 5
Reading:  1 2 3 4 5
Self-study:  1 2 3 4 5
Questions:  1 2 3 4 5


2. Please rate from 1 (lowest)……….5 (highest)

What was the degree of ease, if needed, in communicating with me:  1 2 3 4 5
What is the quality of reading materials (ie professional in appearance,
accurate information, free of typos):		  1 2 3 4 5
Was there adequate support for the content questions:  1 2 3 4 5
Were the unit objectives supported by the home study materials:  1 2 3 4 5
Were assignments carried out in a private and secure manner:  1 2 3 4 5
Did the content lend itself to a home study format:  1 2 3 4 5


3. How many hours/minutes did the following pieces take you?

Reading:
Self-study:
Questions:


4. Anything else you’d like to say?


5. Your Helping Profession:


6. Organization Requiring CEUs:


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