Reference Form

Your reference supports a safer environment for those we care for. For further information, feel free to contact us on 0208 050 2061

Clinical Reference Request Form

Referee Information

*Are you the candidates line manager?

Candidate Information

*Is Candidate still working with you?

*Do you object to us discussing the contents of this reference with the candidate?

Candidate Performance

Very PoorPoorAverageGoodVery Good
Honest & Trustworthy
Ability to do the job?
Ability to work with others?
Ability to receive feedback/criticism?
Ability to adapt?
Willingness to learn?
Willingness to participate?
Work ethic?
Quality of work?

Candidate Traits

Rate the candidates' overall positive qualities


Have you referred the Applicant to DBS (England & Wales), SSSC (Scotland), NMC or any other regulatory body or professional body?
Are there any specific reasons or concerns that lead you to question the candidate's suitability for a care environment that serves a diverse range of vulnerable individuals?
Has the applicant been subject to any concerns regarding safeguarding issues or disciplinary investigations/procedures?

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