Applicant Recommendation Form

To the Applicant: The purpose of this form is for the selection committee to gain insight on your ability to
partake in graduate study in psychology. This form should be given to a person (preferably a
professor/lecturer, employer etc.) who will be able to comment on your qualifications and suitability for
graduate study and professional work in psychology. At least ONE of the two required referees should be an
academician (if not possible due to valid reasons, please ensure that at least one referee is from a clinical
setting). Please inform your referee to forward the completed form to you in a sealed envelope with the flap of
the envelope bearing his/her signature.

To be completed by Applicant:

Applicant Name: _Zureen Allysha binti Zuharman________ Contact Number: 019-3880319

Program Applied For: Master of Clinical Psychology (MCP) Intake Year: 2023

To be completed by Referee: (CONFIDENTIAL)

Referee Name: Diana Nuraimee binti Sapawi Title: Ms

Institution/Company: Mutiara International Grammar School Position: Academician / Jr Teacher

Contact Number: 011-16101079 Email:

diana1010@edidik.edu.my
1. How long have you known the applicant? 17 years 9 months

2. What is your relationship to the applicant? Former Students

3. How well do you know the applicant?

Not well Somewhat Well / Very well

4. Based on your interaction with the applicant, how would you rate his/her current ability in terms of:

Below Above Truly Unable to

Average
Average Average Exceptional Judge
Written communication /
Verbal communication /
Problem-solving ability /
Innovative thinking /
Maturity of judgment /
Work commitment /
Capacity to handle stress /
Ability to work independently /
Ability to work with others /
Accurate self-evaluation /
Receptivity to criticism /
Teachability /

As of December 2022
5. Based on your interaction with the applicant, please rate the applicant on the following characteristics by
marking an ‘X’ along any point of each respective continuum. If unable to judge, please circle ‘N/A’.

Anxious ---------------------------------------------------------------------------X Calm N/A

Careless ---------------------------------------------------------------------------X Conscientious N/A

Rigid ---------------------------------------------------------------------------X Open to experience N/A

Hostile ----------------------------------------------------------------X Agreeable N/A

Insensitive Sensitive
---------------------------------------------------------------------------X N/A
to others to others

Callous ---------------------------------------------------------------------------X Empathic N/A

Please indicate if there are any concerns you would like to raise regarding the applicant.

She doesn’t stumble under pressure. and carries herself very well in every situation she is in. She

conscientious in her act and a very focus as well as a determined individual. She takes up responsibility

impressively well. A leader material young lady, trustworthy and diligent.

6. In general, how do you rate the applicant’s potential for clinical or counseling work?
Poor Fair Good / Excellent Cannot determine

7. Overall recommendation:
Not recommended Recommended with some reservations
Recommended / Highly Recommended

8. Please attach a reference letter with this form. Your letter will greatly help the Selection Committee
evaluate the applicant’s suitability for the program, particularly information which pertain to the applicant’s
personal characteristics that would be relevant to the applicant’s graduate study and professional work.

Signature of Referee: Date: 31 August 2023

To the Evaluator/Referee:
Kindly return this form in a SEALED ENVELOPE with your SIGNATURE on the FLAP of the envelope or via
EMAIL directly to puvessha.j@help.edu.my and cc nursyahira.mn@help.edu.my
You may pass the sealed envelope to the applicant to be included in his/her application packet, or mail/e-
mail it directly to:
Ms. Puvessha Jegathisan
Program Chair – Master of Clinical Psychology
Department of Psychology
Level 3, Block B,
HELP University Subang 2,
Persiaran Cakerawala
Seksyen U4, 40150
Shah Alam, Selangor, Malaysia
As of December 2022