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Confidential Applicant Recommendation Form
Name of Applicant (*)
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Date
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Person Completing form (*)
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Relationship
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Years known to Applicant
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May we contact you?
yes
no
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Email Address
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Phone
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TO THE RECOMMENDER: The applicant whose name appears above is applying to J-CHAI, a independent living program for adults with special needs. Please provide your honest evaluation of how well the statements in table describe the applicant. Your candid estimate of his/her abilities will help us to make appropriate placement. Please complete this form and return it directly to the J-CHAI office. This recommendation is confidential.
Motivated
Unable To Judge
Not True
Sometimes True
Often True
Always True
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Reliable
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Self-advocates
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Follows a daily schedule
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Uses strategies to cope with stress
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Easily adjusts to new situations
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Generally liked by peers
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Gets along with people of authority
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Able to use people as a resources
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Reacts appropriately to emergencies
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Often loses temper
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Often seems worried
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Lacks confidence in new situations
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Separates own problems from those of others
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Trouble making everyday decisions
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Easily distracted, concentration wanders
Unable To Judge
Not True
Sometimes True
Often True
Always True
Invalid Input
Strengths of applicant
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General comments and concerns
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How likely is this applicant to succeed living independently?
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Submit
J-CHAI Application
Complete Application Procedures
J-CHAI Application Part 1
J-CHAI Application Part 2
J-CHAI Application Part 3
Applicant Questionnaire
Parent/Guardian Questionnaire
Confidential Applicant Recommendation Form
Authorization Form
Download Application (PDF format)
Download Recommendation Form (PDF format)
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