Western Kentucky University
Department of Counseling and Student Affairs
School Counseling Site Supervisor Evaluation Form
Student Name: _________________________________
Date: ________________
Site Supervisor’s Name: __________________________________________
Name of Site: ____________________________________
Grade Levels: _________
Please indicate Course: ______ Practicum _____ Internship I
_____ Internship II
This evaluation is for: _____ Midterm
_____ Final Evaluation of Semester
The site supervisor will complete this form at the midterm and at the end of each semester. Mark
the number to the right of each item that best describes your perceptions of the intern’s skill compared to
all other people you have trained at the same level of professional development. The term “client” as
used herein refers to any person receiving services including students, parents, or teachers.
IO = Inadequate Opportunity to Observe
NR = Not Relevant to the Setting
Counseling Skill
Competency
Clearly
Meets
Deficient Expectation Outstanding
1
2
3
4
5
IO
NR
1. Establishesaworkingrelationshipwith clients.
1
2
3
4
5
IO
NR
2. Establishes relevant counseling goals with or for
clients.
1
2
3
4
5
IO
NR
3. Evaluates clients’ progress with respect to goals.
1
2
3
4
5
IO
NR
4. Facilitates clients’ resolution of concerns.
1
2
3
4
5
IO
NR
5. Appropriately refers and terminates clients.
1
2
3
4
5
IO
NR
6. Understands theoretical principles as applied to
particular client problems.
1
2
3
4
5
IO
NR
7. Understands diverse cultural, ethnic, sexual and
social backgrounds and values of clients.
1
2
3
4
5
IO
NR
Revised12/2015
8. Demonstrates ethical behavior in the counseling
activity and case management.
1
2
3
4
5
IO
NR
9. Demonstrates competence in creating and
implementing a career transition plan.
1
2
3
4
5
IO
NR
1. Meets with supervisor as scheduled.
Clearly
Meets
Deficient Expectations Outstanding
1
2
3
4
5 IO NR
1
2
3
4
5
IO
NR
2. Engages in open, comfortable and clear
communication with peers and supervisors.
1
2
3
4
5
IO
NR
1
2
3
4
5
IO
NR
1
2
3
4
5
IO
NR
Supervision Competency
3. Accepts and uses constructive feedback to
enhance self-development and counseling
skills.
4. Open to growth and learning.
Case Management Skill Competency
Clearly
Meets
Deficient Expectation Outstanding
1
2
3
4
5 IO NR
12345IONR
Appropriately uses referrals within and outside the 12345IONR
site.
12345IONR
Consistently schedules and meets with clients.
12345IONR
Keeps adequate and timely client records.
Consults with other staff regarding client needs.
12345IONR
Fulfills administrative responsibilities of the
12345IONR
position.
1. Aware of community resources.
2.
3.
4.
5.
6.
Revised12/2015
Clearly
Meets
Deficient Expectation Outstanding
1
2
3
4
5 IO NR
Professional School Counseling
Skill Competency
1
2
3
4
5
IO
NR
1
2
3
4
5
IO
NR
3. Demonstrates knowledge of the school setting,
climate, curriculum, and current issues impacting
the school environment.
1
2
3
4
5
IO
NR
4. Displays sensitivity to cross cultural issues in the
school and community as well as opportunities
and barriers to student development.
1
2
3
4
5
IO
NR
5. Identifies and consults during ethical and legal
issues.
1
2
3
4
5
IO
NR
6. Utilizes individual and small group counseling,
and classroom guidance approaches to promote
student success in school.
1
2
3
4
5
IO
NR
7. Exhibits advocacy skills for all students, the
school counseling program, the profession,
and self.
1
2
3
4
5
IO
NR
1
2
3
4
5
IO
NR
9. Displays effort toward integrating the school
counseling program into the total school
curriculum.
1
2
3
4
5
IO
NR
10. Demonstrates skill in individual, family and
school crisis prevention programs and
intervention strategies.
1
2
3
4
5
IO
NR
1. Demonstrates knowledge of the relationship
between the school counseling program and the
other functioning units and personnel in the
school.
2. Demonstrates leadership skills, which enhance the
learning environment of the school.
8. Demonstrates skill in coordination, collaboration,
referrals, and team building with the various
stakeholders associated with the school.
Revised12/2015
1
2
3
4
5
IO
NR
12. Displays leadership skills in using schoolbased data to improve student outcomes.
1
2
3
4
5
IO
NR
13. Exhibits ability to implement and evaluate
strategies to meet program goals.
1
2
3
4
5
IO
NR
14. Able to identify student needs and
implement processes or activities to help
students achieve.
1
2
3
4
5
IO
NR
15. Uses technology to design, implement, monitor,
and evaluate the school counseling program.
1
2
3
4
5
IO
NR
1
2
3
4
5
IO
NR
17. Recognizes how systems and relationships interact 1
to influence students and each other.
2
3
4
5
IO
NR
1
2
3
4
5
IO
NR
1
2
3
4
5
IO
NR
11. Engages in planning, developing,
implementing, monitoring, and evaluation of
the counseling program.
16. Manages issues affecting the development or
functioning of students (e.g., LD, ADHD, ADD,
ODD, etc.).
18. Recognizes and assists students who may use
alcohol and/or other drugs.
19. Uses consultation strategies to enhance teamwork
within the school and community.
Based on your experiences, what would you evaluate as being the student’s major strengths?
________________________________________________________________
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Revised12/2015
Suggestions for further professional development:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
____________________________________
Signature of Site Supervisor
_________________
Date
__________________________________
Signature of Faculty Supervisor
_________________
Date
My signature indicates I have read and discussed the above material with
my site and faculty supervisors. It does not indicate my total or partial agreement
with the evaluation.
_____________________________________
Signature of Practicum/Intern Student
_________________
Date
Instructions for completing this form:
1. Save this form to your computer. Save with the file name: Your Last Name + Your First Initial +
Supervisor Mid or Final Eval + MonthYear. For example, “JohnsonLSupervisorMidEval0414”
2. Electronically send the entire document to your Site Supervisor. Ask the Site Supervisor to complete
the form on their computer, re-save it in the same format, and then e-mail it back to you.
3. Electronically send the completed form to your Practicum or Internship Instructor/Supervisor and the
School Counseling Clinical Coordinator with your electronic portfolio at the end of the semester.
Revised12/2015