Name of Student: _________________________ Semester/Year: ___________________ Supervisor: ______________________________ Grade: __________________________ Check One: _______ Mid‐Term ______ Final Stephen F. Austin State University
Clinical Evaluation Form
Entry Level & Primary Level
5
INTERPERSONAL SKILLS (Average score for area)
1.
Interactions With Client
a. Relates comfortably to client.
b. Attending behavior: Attends to client’s total behavior so emphasis
is placed on interaction with client, not therapy procedures.
2.
Interactions With Others
a.
Conveys therapy goals and progress to professional and parent.
b. Responds to suggestions made by supervisor.
c.
Interacts appropriately with other professionals.
d. Demonstrates a professional attitude towards supervisor.
e.
Demonstrates a professional attitude towards other clinicians.
TECHNICAL SKILLS (Average score for area)
1.
Therapy Planning – Short Term
a.
Formulates objectives on a session to session basis.
b. Uses materials that are attractive, motivating and appropriate
for client’s mental and/or chronological age.
c. Has rationale for selected procedures; maximizes number
and types of responses.
d. Modifies program when change is indicated.
2.
e.
Plan means for demonstrating progress.
f.
Writes semester progress report
Therapy Planning – Long Term
a.
Formulates reasonable long-term objectives
4
3
2
1
5
3.
Therapy Execution
a.
Takes baseline measures.
b. Written objectives congruent with actual procedures used.
c.
Uses appropriate language for client’s mental and language abilities.
d. Identifies target behaviors.
e.
Gives client sufficient time to respond.
f.
Uses appropriate correction techniques.
g.
Discriminates error from target behavior
h. Uses appropriate correction techniques.
i.
Gives consistent, concise and concrete feedback.
j.
Accurately records responses.
k. Integrates session in a smooth manner.
l.
4.
Demonstrates flexibility when following lesson plans.
Behavior Management
a.
Manipulates the environment in order to facilitate optimal behavior.
b. Deals appropriately with client’s unacceptable behavior.
DIAGNOSTICS (Average score for this area)
1.
Diagnostic Preparation
2.
Diagnostic Execution – Administers Tests Appropriately
3.
Interpretation of Diagnostic Information
4.
Report Writing
PERSONAL RESPONSIBILITIES (Average score for area)
1.
Dresses according to clinic standards.
2.
Takes responsibility for materials borrowed.
3.
Respects time schedules for others.
4.
Demonstrates appropriate attendance for clinical responsibilities
4
3
2
1
5
5.
Prepares for supervisory conference.
6.
Contributes alternative procedures during discussion of clients.
7.
Evaluates own clinical performance.
8.
Keeps personal concerns and problems from interfering with therapy.
9.
Proactively communicates personal circumstances
affecting practicum responsibilities.
10. Submits paperwork in a timely manner.
11. Maintains confidentiality.
4
3
2
1
Stephen F. Austin State University
Clinical Evaluation Form
Entry Level & Primary Level
COMMENTS:
Grade Computation if average for Personal Responsibilities is above 3.5:
(Average score for Interpersonal Skills) + (Average score for Technical Skills) + (Average score for Diagnostic
Skills) / 3 =
Grade computation for Personal Responsibilities is below 3.5:
(Average score for Interpersonal Skills) + (Average score for Technical Skills) + (Average score for Diagnostic
Skills) + (Average for Personal Responsibilities multiplied by 2) and this total divided by 4 =
Mid-Term Average: __________________
Areas to be monitored: ________ Lesson planning/preparation
Final Average: __________________
________ Behavior
________ Therapy Implementation
________ Therapy Activities
________ Teaching
________ Level of Support
________ Reinforcement
________ Diagnostics
COMPLETED BY: _____ STUDENT
_____ SUPERVISOR
STUDENTS SIGNATURE: __________________________________________ DATE: ______________________
SUPERVISORS SIGNATURE: _______________________________________ DATE: _____________________