Boost 200 Recommendation Form

What is Boost 200?

Boost 200 is a special initiative to accelerate licensure of 200 Masters-prepared individuals pursuing licensure in Virginia as a Licensed Professional Counselor (LPC) , Licensed Clinical Social Worker (LCSW) or Licensed Marriage and Family Therapist (LMFT) by paying for their required Supervision hours.

The ideal Boost 200 candidate is a recent MC, MSW or MMFT graduate or a Supervisee in Social Work/Licensed Resident in Counseling or Marriage and Family Therapy pursuing licensure as a Licensed Professional Counselor, Licensed Clinical Social Worker or Licensed Marriage and Family Therapist in Virginia, and who is:

Paying out-of-pocket for some or all of their Supervision and
Prepared, motivated, energetic, and ready to complete their clinical and Supervision hours.

This Recommendation Form should be completed by someone who has supervised the Boost 200 applicant for at least 100 internship hours and familiar with the applicant's current

clinical skills and experience.

A completed recommendation form is required for all Boost 200 applicants.

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* 1. Your Information:

First Name

Last Name

Title

Employer

Email Address

Phone Number

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* 2. Boost 200 Applicant's Information:

First Name

Last Name

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* 3. What type of degree does the Boost 200 applicant hold?

Masters of Social Work

Masters of Counseling

Masters of Marriage and Family Therapy

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* 4. How long have you known the Boost 200 applicant?

< 1 year

1 - 3 years

3 - 4 years

> 4 years

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* 5. Select the option that best describes your relationship to the Boost 200 applicant:

Other (please specify)

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* 6. On the scale below, please rate the applicant relative to other recent Counseling or Social Work graduates (or Supervisees/Residents in Counseling) you know who are pursuing licensure in Virginia.

	Exceptional (Top 2%)	Excellent (Top 5%)	Very Good (Top 10%)	Good (Top 25%)	Average (50%)	Poor (Below 50%)
Motivation and Energy to Become Licensed	Motivation and Energy to Become Licensed Exceptional (Top 2%)	Motivation and Energy to Become Licensed Excellent (Top 5%)	Motivation and Energy to Become Licensed Very Good (Top 10%)	Motivation and Energy to Become Licensed Good (Top 25%)	Motivation and Energy to Become Licensed Average (50%)	Motivation and Energy to Become Licensed Poor (Below 50%)
Ability to Work Autonomously	Ability to Work Autonomously Exceptional (Top 2%)	Ability to Work Autonomously Excellent (Top 5%)	Ability to Work Autonomously Very Good (Top 10%)	Ability to Work Autonomously Good (Top 25%)	Ability to Work Autonomously Average (50%)	Ability to Work Autonomously Poor (Below 50%)
Ability to Work with Other Health Professionals	Ability to Work with Other Health Professionals Exceptional (Top 2%)	Ability to Work with Other Health Professionals Excellent (Top 5%)	Ability to Work with Other Health Professionals Very Good (Top 10%)	Ability to Work with Other Health Professionals Good (Top 25%)	Ability to Work with Other Health Professionals Average (50%)	Ability to Work with Other Health Professionals Poor (Below 50%)
Emotional Maturity	Emotional Maturity Exceptional (Top 2%)	Emotional Maturity Excellent (Top 5%)	Emotional Maturity Very Good (Top 10%)	Emotional Maturity Good (Top 25%)	Emotional Maturity Average (50%)	Emotional Maturity Poor (Below 50%)
Professionalism	Professionalism Exceptional (Top 2%)	Professionalism Excellent (Top 5%)	Professionalism Very Good (Top 10%)	Professionalism Good (Top 25%)	Professionalism Average (50%)	Professionalism Poor (Below 50%)
Clinical Ability	Clinical Ability Exceptional (Top 2%)	Clinical Ability Excellent (Top 5%)	Clinical Ability Very Good (Top 10%)	Clinical Ability Good (Top 25%)	Clinical Ability Average (50%)	Clinical Ability Poor (Below 50%)
Dependability	Dependability Exceptional (Top 2%)	Dependability Excellent (Top 5%)	Dependability Very Good (Top 10%)	Dependability Good (Top 25%)	Dependability Average (50%)	Dependability Poor (Below 50%)
Ability to Manage Stress	Ability to Manage Stress Exceptional (Top 2%)	Ability to Manage Stress Excellent (Top 5%)	Ability to Manage Stress Very Good (Top 10%)	Ability to Manage Stress Good (Top 25%)	Ability to Manage Stress Average (50%)	Ability to Manage Stress Poor (Below 50%)
Ability to Communicate Effectively	Ability to Communicate Effectively Exceptional (Top 2%)	Ability to Communicate Effectively Excellent (Top 5%)	Ability to Communicate Effectively Very Good (Top 10%)	Ability to Communicate Effectively Good (Top 25%)	Ability to Communicate Effectively Average (50%)	Ability to Communicate Effectively Poor (Below 50%)

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* 7. Please indicate your recommendation of the applicant for Boost 200:

I strongly recommend this applicant for Boost 200.

I recommend this applicant for Boost 200.

I recommend this applicant for Boost 200 with some reservation.

I do not recommend this applicant for Boost 200.

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* 8. Optional: You are welcome to provide a narrative in support of the applicant's application for Boost 200. If you would like to submit a written assessment to complement the required chart, please provide on a separate page (limited to 1-page double spaced, Arial, 12-pt. font)

PDF, DOC, DOCX file types only.

Choose File

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* 9. By checking "I agree" below and clicking "Submit" below, you are indicating that you have completed the Boost 200 recommendation form on behalf of the applicant accurately to the best of your ability.

I agree

I do not agree

Boost 200 is a special initiative of the Virginia Health Care Foundation,
funded by the Virginia General Assembly and the Virginia Department of Behavioral Health and Developmental Services.