Department of Counseling, Administration, Supervision & Adult Learning
College of Education
Evaluation of Counseling Intern by the Site Supervisor
Student: ______________________________________________________
Supervisor: ____________________________________________________
Site Location: __________________________________________________
Date: _________________________________________________________
Please complete the following items as intern’s on-site supervisor. These items are designed to
assess the following:
The intern’s knowledge and understanding of counseling theory and practice
The intern’s performance of skills related to counseling practice
The intern’s beliefs and attitudes relevant to counseling practice
Please use the following rating scale on each page and circle your response.
0 = Unacceptable
1 = Marginal
2 = Proficient
3 = Exemplary
NA = Does Not Apply to your work with this intern
Understanding Individual Counseling Theory [Knowledge Base: Facilitation]
Intern demonstrates theoretical knowledge and flexibility in case conceptualization
0 ----- 1 ----- 2 ----- 3
NA
Intern selects and applies appropriate theory-based interventions
0 ----- 1 ----- 2 ----- 3
NA
Intern developed self-efficacy in their application of theory to practice
0 ----- 1 ----- 2 ----- 3
Intern Evaluation/rev.
2010
1
NA
0 = Unacceptable
1 = Marginal
2 = Proficient
3 = Exemplary
NA = Does Not Apply to your work with this intern
Understanding Theories of Human Development [Knowledge Base: Facilitation]
Intern displays sensitivity to clients’ relevant developmental areas
0 ----- 1 ----- 2 ----- 3
NA
Intern selected and applied developmentally appropriate interventions
0 ----- 1 ----- 2 ----- 3
NA
Intern demonstrates a belief in identifying and using clients’ strengths to promote growth and
change
0 ----- 1 ----- 2 ----- 3
NA
Understanding of Psychopathology [Knowledge Base: Personal/Social]
Intern was able to recognize and identify symptoms across of range of psychopathology
0 ----- 1 ----- 2 ----- 3
NA
Intern selected and applied interventions appropriate to clients’ diagnoses
0 ----- 1 ----- 2 ----- 3
NA
Intern demonstrated respect and unconditional positive regard for all clients
0 ----- 1 ----- 2 ----- 3
NA
Understanding of Career Development [Knowledge Base: Career]
Intern was able to conceptualize career/college choice dilemmas using career development
theories
0 ----- 1 ----- 2 ----- 3
NA
Intern selected appropriate interventions to assist clients with career/college choices
0 ----- 1 ----- 2 ----- 3
NA
Intern demonstrated awareness of clients’ career challenges, struggles and successes
0 ----- 1 ----- 2 ----- 3
NA
Assessment of Individual’s Personal, Educational, Interpersonal, and Career Concerns
[Knowledge Base: Personal/Social]
Intern was able to include information from a variety of sources when developing and presenting
case conceptualizations
0 ----- 1 ----- 2 ----- 3
Intern Evaluation/rev.
2010
2
NA
0 = Unacceptable
1 = Marginal
2 = Proficient
3 = Exemplary
NA = Does Not Apply to your work with this intern
Intern used information from a variety of sources when applying interventions
0 ----- 1 ----- 2 ----- 3
NA
Intern demonstrated respect and empathy for clients’ life complexities
0 ----- 1 ----- 2 ----- 3
NA
Understanding and Applying Group Facilitative Skills [Knowledge Base: Personal/Social]
Intern appropriately applied group theory when forming, working with, and ending a group
0 ----- 1 ----- 2 ----- 3
NA
Intern selected interventions appropriate to the nature of the group
0 ----- 1 ----- 2 ----- 3
NA
Intern was able to articulate and reflect on the impact of the group experience
0 ----- 1 ----- 2 ----- 3
NA
Planning, Developing, Managing and Evaluating Counseling Programs [Knowledge Base:
Educational, Personal/Social
Intern understands counseling programs from an organizational level
0 ----- 1 ----- 2 ----- 3
NA
Intern demonstrated program planning, development, management, and/or evaluation skills
0 ----- 1 ----- 2 ----- 3
NA
Intern expressed a willingness to be involved at the program level
0 ----- 1 ----- 2 ----- 3
NA
Applications of Individual Counseling Skills to Assist Clients in Planning and Alleviating
Personal/Social Issues Which Interfere with Development [Knowledge Base: Educational,
Personal/Social]
Intern demonstrated the knowledge of the components in a plan of action or a treatment plan
0 ----- 1 ----- 2 ----- 3
NA
Intern was skillful in assisting clients with formulating plans of action or treatment plans
0 ----- 1 ----- 2 ----- 3
NA
Intern demonstrated confidence in assisting clients with action or treatment plans
0 ----- 1 ----- 2 ----- 3
Intern Evaluation/rev.
2010
3
NA
0 = Unacceptable
1 = Marginal
2 = Proficient
3 = Exemplary
NA = Does Not Apply to your work with this intern
Appreciation of the Effects of Our Cultural and Social Heritage on Human Development
[Knowledge Base: Facilitation]
Intern demonstrated awareness and understanding of cultural differences
0 ----- 1 ----- 2 ----- 3
NA
Intern used counseling skills that demonstrated sensitivity to cultural differences
0 ----- 1 ----- 2 ----- 3
NA
Intern appreciates and values client diversity
0 ----- 1 ----- 2 ----- 3
NA
Understanding of Research Theory and its Applications [Knowledge Base: Facilitation]
Intern referenced the counseling literature when formulating case conceptualizations
0 ----- 1 ----- 2 ----- 3
NA
Intern demonstrated research skills when engaged in program development and/or evaluation
0 ----- 1 ----- 2 ----- 3
NA
Intern demonstrated an understanding of the value of counseling research and literature to
clinical practice
0 ----- 1 ----- 2 ----- 3
NA
Appreciate the Application Principles of Professional Ethics and State, Local, and National
Laws [Knowledge Base: Facilitation, Career]
Intern used Professional Code of Ethics when making ethical decisions
0 ----- 1 ----- 2 ----- 3
NA
Intern took action that followed the Professional Code of Ethics
0 ----- 1 ----- 2 ----- 3
NA
Intern adhered to the ethics of the counseling profession
0 ----- 1 ----- 2 ----- 3
Intern Evaluation/rev.
2010
4
NA
We would also appreciate knowing the following about your experience with your CSU
intern:
Please tell us more about the intern’s relationship with you and other staff, including the
ability to seek assistance when necessary, to implement supervisory feedback, etc.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please comment on:
a. The intern’s competence in maintaining case notes and other written materials.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Intern Evaluation/rev.
2010
5
b. Special skills/strengths.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
c. Areas for improvement.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
THANK YOU FOR YOUR EVALUATION
Intern Evaluation/rev.
2010
6