This document is a reference form for applicants to Youth With A Mission (YWAM)-Nashville. It requests information about the applicant from a reference such as how well they know the applicant, ratings of traits like initiative and dependability, and recommendations on whether the applicant should be accepted. The reference is asked to provide details on the applicant's strengths, relationships, family background, and whether at least a two-year commitment to missionary service would benefit the applicant.
Box 13-7 Family Assessment GuideI Identifying Data· Name ____VannaSchrader3
Box 13-7 Family Assessment Guide
I Identifying Data
· Name: ___________________________________________________________________________________________________
· Address: __________________________________________________________________________________________________
· Phone number(s):_____________________________________________________________________________________________
· Household members (relationship, gender, age, occupation, education):____________________________________________________
· Financial data (sources of income, financial assistance, medical care; expenditures):___________________________________________
· Ethnicity: __________________________________________________________________________________________________
· Religion: __________________________________________________________________________________________________
· Identified client(s):______________________________________________________________________________________________
· Source of referral and reason: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
II Genogram
· Include household members, extended family, and significant others
· Age or date of birth, occupation, geographical location, illnesses, health problems, major events
· Triangles and characteristics of relationships
III Individual Health Needs (for each household family member)
· Identified health problems or concerns: ________________________________________________________________________________
· Medical diagnoses: _____________________________________________________________________________________________
· Recent surgery or hospitalizations: _________________________________________________________________________________
· Medications and immunizations: _________________________________________________________________________________
· Physical assessment data: ______________________________________________________________________________________
· Emotional and cognitive functioning: _______________________________________________________________________________
· Coping: _____________________________________________________________________________________________________
· Sources of medical and dental care: ____________________________________________________________________________
· Health screening practices: ____________________________________________________________________________________
IV Interpersonal Needs
· Identified subsystems and dyads:________________________________________________________________________________
· Prenatal care needed: ________________________________________________________________________ ...
Formulating a Family Care PlanI Identifying Data· Name ______JeanmarieColbert3
Formulating a Family Care Plan
I Identifying Data
· Name: __________________________________________________________________________________________________
· Address: __________________________________________________________________________________________________
· Phone number(s):_____________________________________________________________________________________________
· Household members (relationship, gender, age, occupation, education):____________________________________________________
· Financial data (sources of income, financial assistance, medical care; expenditures):___________________________________________
· Ethnicity: __________________________________________________________________________________________________
· Religion: __________________________________________________________________________________________________
· Identified client(s):______________________________________________________________________________________________
· Source of referral and reason: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
II Genogram
· Include household members, extended family, and significant others
· Age or date of birth, occupation, geographical location, illnesses, health problems, major events
· Triangles and characteristics of relationships
III Individual Health Needs (for each household family member)
· Identified health problems or concerns: ________________________________________________________________________________
· Medical diagnoses: _____________________________________________________________________________________________
· Recent surgery or hospitalizations: _________________________________________________________________________________
· Medications and immunizations: _________________________________________________________________________________
· Physical assessment data: ______________________________________________________________________________________
· Emotional and cognitive functioning: _______________________________________________________________________________
· Coping: _____________________________________________________________________________________________________
· Sources of medical and dental care: ____________________________________________________________________________
· Health screening practices: ____________________________________________________________________________________
IV Interpersonal Needs
· Identified subsystems and dyads:________________________________________________________________________________
· Prenatal care needed: __________________________________________________________________________ ...
Box 13-7 Family Assessment GuideI Identifying Data· Name ____VannaSchrader3
Box 13-7 Family Assessment Guide
I Identifying Data
· Name: ___________________________________________________________________________________________________
· Address: __________________________________________________________________________________________________
· Phone number(s):_____________________________________________________________________________________________
· Household members (relationship, gender, age, occupation, education):____________________________________________________
· Financial data (sources of income, financial assistance, medical care; expenditures):___________________________________________
· Ethnicity: __________________________________________________________________________________________________
· Religion: __________________________________________________________________________________________________
· Identified client(s):______________________________________________________________________________________________
· Source of referral and reason: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
II Genogram
· Include household members, extended family, and significant others
· Age or date of birth, occupation, geographical location, illnesses, health problems, major events
· Triangles and characteristics of relationships
III Individual Health Needs (for each household family member)
· Identified health problems or concerns: ________________________________________________________________________________
· Medical diagnoses: _____________________________________________________________________________________________
· Recent surgery or hospitalizations: _________________________________________________________________________________
· Medications and immunizations: _________________________________________________________________________________
· Physical assessment data: ______________________________________________________________________________________
· Emotional and cognitive functioning: _______________________________________________________________________________
· Coping: _____________________________________________________________________________________________________
· Sources of medical and dental care: ____________________________________________________________________________
· Health screening practices: ____________________________________________________________________________________
IV Interpersonal Needs
· Identified subsystems and dyads:________________________________________________________________________________
· Prenatal care needed: ________________________________________________________________________ ...
Formulating a Family Care PlanI Identifying Data· Name ______JeanmarieColbert3
Formulating a Family Care Plan
I Identifying Data
· Name: __________________________________________________________________________________________________
· Address: __________________________________________________________________________________________________
· Phone number(s):_____________________________________________________________________________________________
· Household members (relationship, gender, age, occupation, education):____________________________________________________
· Financial data (sources of income, financial assistance, medical care; expenditures):___________________________________________
· Ethnicity: __________________________________________________________________________________________________
· Religion: __________________________________________________________________________________________________
· Identified client(s):______________________________________________________________________________________________
· Source of referral and reason: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
II Genogram
· Include household members, extended family, and significant others
· Age or date of birth, occupation, geographical location, illnesses, health problems, major events
· Triangles and characteristics of relationships
III Individual Health Needs (for each household family member)
· Identified health problems or concerns: ________________________________________________________________________________
· Medical diagnoses: _____________________________________________________________________________________________
· Recent surgery or hospitalizations: _________________________________________________________________________________
· Medications and immunizations: _________________________________________________________________________________
· Physical assessment data: ______________________________________________________________________________________
· Emotional and cognitive functioning: _______________________________________________________________________________
· Coping: _____________________________________________________________________________________________________
· Sources of medical and dental care: ____________________________________________________________________________
· Health screening practices: ____________________________________________________________________________________
IV Interpersonal Needs
· Identified subsystems and dyads:________________________________________________________________________________
· Prenatal care needed: __________________________________________________________________________ ...
1. YWAM Leader Reference Form
TO THE APPLICANT: Please complete the information below and provide a stamped envelope addressed to:
Youth With A Mission-Nashville: Personnel Department – P.O. Box 58 – Adams, TN 37010
Name of Applicant: _______________________________________________ Phone #: ___________________________
Street Address: _______________________________________ City: ________________ State: _____ Zip: ___________
Applying For: _____________________________________________________ Date Beginning: ____________________
I, the above named applicant, waive any right I have to read or obtain copies of this recommendation knowing that this
waiver is not required as a condition for admission.
Applicant’s Signature: _______________________________________________________ Date: ____________________
FOR REFERENCE ONLY
The above applicant has applied for admission to Youth With A Mission – Nashville. Serious consideration will
be given to your comments. Therefore, we ask that you complete this form carefully. Your early response will be most
appreciated as the applicant’s file cannot be considered until all forms have been received by this office. Thank you
for taking time to help us in this way. We sincerely appreciate your cooperation.
Please check the following and comment where necessary:
Your relationship to the applicant: □ School Leader □ Small Group Leader □ Outreach Leader □ Other: _____________
How well do you know the applicant?: □ Very Well □ Well □ Casually □ Not Well
Please rate the following and provide comments where necessary:
Excellent Good Fair Poor No Observation
Initiative □ □ □ □ □
Self – Discipline □ □ □ □ □
Self – Image □ □ □ □ □
Ability to Work with Others □ □ □ □ □
Concern for Others □ □ □ □ □
Desire to Serve □ □ □ □ □
Social Acceptability □ □ □ □ □
Work Ethic □ □ □ □ □
Dependability □ □ □ □ □
Emotional Stability □ □ □ □ □
Judgment / Decision Making □ □ □ □ □
Adaptability □ □ □ □ □
Ability to Follow □ □ □ □ □
Ability to Lead □ □ □ □ □
Financial Stewardship □ □ □ □ □
Personal Devotions □ □ □ □ □
Perseverance □ □ □ □ □
Additional Comments: _______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
2. 1. How long have you known the applicant?: __________ years
2. How long have they attended your church?: __________ years
3. Were you aware of the applicant’s intention to join us on staff? □ No □ Yes
4. Were schools and outreaches completed to your satisfaction? □ No □ Yes
If No, please explain: __________________________________________________________________________
___________________________________________________________________________________________
5. Please comment on the applicant’s strengths and gifting’s: ___________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
6. How would you best describe the applicant’s relationship with the Lord?
□ Mature □ Contagious □ Genuine and Growing □ Over-emotional □ Superficial
Please explain: _______________________________________________________________________________
___________________________________________________________________________________________
7. Please comment on the applicant’s family background (if known): ______________________________________
___________________________________________________________________________________________
8. What is your recommendation for the applicant?
□ To be accepted on staff □ Not to be accepted on staff
Is your recommendation:
□ Strong □ Moderate □ Hesitant
9. Does the applicant seem to have any mental or emotional disabilities?: □ No □ Yes
If yes, please explain:__________________________________________________________________________
___________________________________________________________________________________________
10. Can you give any other information concerning applicant that might aid us in our decision?:
___________________________________________________________________________________________
___________________________________________________________________________________________
11. Do you think that (at least) a two-year commitment to missionary service would be beneficial, or unwise at this
point to the applicant? □ Beneficial □ Unwise
Please explain: _______________________________________________________________________________
___________________________________________________________________________________________
FOR REFERENCE ONLY
Name: _________________________________________ Title: ___________________ Phone #: ___________________
Address: _________________________________________ Email: ____________________________________________
City: _________________________________________ State: ___________________ Zip Code: ____________________
Signature: _______________________________________________________________ Date: _____________________
Would you like to receive further information about YWAM – Nashville? □ No □ Yes