Western Illinois University Counselor Education Internship Student Evaluation Student Information Name Internship Site Date Supervisor Review Period Start Date End Date Total Hours Completed (Required) Professionalism Proper Attire, professional appearance Arrives on time Completes assignments on time Communications skills – uses tact and diplomacy with others Ethical behavior – knowledge of an adherence to ACA Code of Ethics Additional Comments 1 = Poor 2 = Fair 3 = Satisfactory 4 = Good 5 = Excellent N/A †
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† † † † † † † † † † † † † † † † † † † † † † † † † † Page 1 of 6 Social and Cultural Diversity 1 = Poor 2 = Fair 3 = Satisfactory 4 = Good 5 = Excellent N/A Knowledge and application of theories of multi‐cultural counseling † † † † † † Engages in social justice, advocacy, and conflict resolution † † † † † † 1 = Poor 2 = Fair 3 = Satisfactory 4 = Good 5 = Excellent N/A Demonstrates knowledge of counseling theories that effectively conceptualizes client presentation and selects and implements appropriate counseling interventions † † † † † † Demonstrates knowledge of a systems perspective that recognizes family and other systems theories and related interventions † † † † † † Additional Comments Helping Relationships Additional Comments Page 2 of 6 Professional Dispositions 1 = Poor 2 = Fair 3 = Satisfactory 4 = Good 5 = Excellent N/A Demonstrates appropriate self‐control (such as anger control, impulse control) in interpersonal relationships †
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† † † † Demonstrates honesty, fairness, and respect for others † † † † † † Able to conceptualize and explain cultural differences † † † † † † † † † † † † † † † † † † † † † † † † † † † † † † Demonstrates an awareness of his or her own belief systems, values, needs and limitations and the effect of these on his or her work Demonstrates the ability to receive, integrate and utilize feedback Exhibits appropriate levels of self‐assurance, confidence, and trust in own ability Follows professionally recognized conflict resolution processes, seeking to informally address the issue first with the individual(s) with whom the conflict exists Additional Comments Page 3 of 6 Action Skills 1 = Poor 2 = Fair 3 = Satisfactory 4 = Good 5 = Excellent N/A Demonstrates ability to structure a counseling session (opening – closing) †
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† † † † Able to define goals in developing programs † † † † † † † † † † † † † † † † † † † † † † † † † † † † † † † † † † † † 1 = Poor 2 = Fair 3 = Satisfactory 4 = Good 5 = Excellent N/A †
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† † † † † † † † † † Able to conceptualize and explain client issues in light of developmental tasks, stages, or issues † † † † † † Able to conceptualize and explain client issues as influenced by family of origin or family of procreation processes † † † † † † Develops schedules Demonstrates appropriate termination skills Uses problem solving and decision‐making skills Demonstrates an advanced integration of techniques Able to renegotiate goals and direction of the session when appropriate Additional Comments Theoretical Skills Demonstrates ability to integrate theoretical assumptions with techniques Able to conceptualize and explain client issues in theoretical terms Page 4 of 6 Able to conceptualize and explain what makes people change Demonstrates continued integration of theory to advanced levels developing an advanced mastery by end of Internship Additional Comments † † † † † † † † † † † † Strengths Please identify the strengths of the internship student. Please provide as much detail as possible. Page 5 of 6 Weaknesses Please identify the weaknesses of the internship student. Please provide as much detail as possible and suggestions for addressing the weakness. Verification of Review By signing this form, you confirm that you have discussed this review in detail with your supervisor. Signing this form does not necessarily indicate that you agree with this evaluation. Internship Student Signature Supervisor Signature Supervisor preferred telephone number Date Supervisor preferred e‐mail address Evaluation reviewed by Date Page 6 of 6