COUN 670
SCHOOL COUNSELING
INTERNSHIP
FALL 2011
TABLE OF CONTENTS
Introduction and State Requirements .....................................................................................p. 2
Sample Syllabus .....................................................................................................................pp. 3-6
Introduction Letter to Supervisors .........................................................................................p. 7
Internship Approval Request Form ........................................................................................pp. 8-9
Expectations for Xavier Interns .............................................................................................p. 10
Xavier University Affiliation Agreement and Instructions ...................................................pp. 11-13
Internship Log Form ..............................................................................................................pp. 14-22
Field Project Information .......................................................................................................p. 23-24
Requesting an Extension……………………………………………………………………pp. 25-26
Student Evaluation Procedures ..............................................................................................p. 27
Xavier University Interim Evaluation Form ..........................................................................p. 28
Final Internship Supervisor Evaluation Rating Form ............................................................pp. 29-32
Confidential Internship Site Evaluation Form………………………………………………p. 33
1
XAVIER
UNIVERSITY
Department of School &
Community Counseling
3800 Victory Parkway
Cincinnati, Ohio 45207-6612
Phone (513) 745 – 3655
Fax (513) 745 – 2920
www.xavier.edu
Dear Students,
This booklet contains some important information and required forms necessary for you to
successfully begin, register, and verify the completion of your counseling internship.
We recommend you read each item thoroughly to help you avoid confusion in determining how the
internship is approved and conducted.
To gain approval to begin your internship experience, all forms must be completed. We also strongly
recommend that you keep copies of all forms filed with Xavier and returned to the clinical
coordinator.
Best wishes for a successful internship experience!
Dr. Butch Losey
Clinical Coordinator
loseyr@xavier.edu
SCHOOL COUNSELING INTERNSHIP
INFORMATION
Students must have successfully completed COUN 669 and 773 (Counseling Pre-Practicum and
Practicum), before taking COUN 670.
OVERVIEW
All students must complete COUN 670 (4 sem. hrs.). COUN 670 requires that a minimum of 600 clock
hours of on-site school counseling activities be completed under the direct supervision of a school
counselor. Of these 600 hours, a minimum of 240 clock hours must be conducted in direct service
activities with clientele. On-campus class meetings are also scheduled as part of this experience. Since
some students are unable to complete the internship in one semester, some students elect to register for
2 semester hours in one semester and 2 semester hours in the following semester.
2
S A M P L E
XAVIER UNIVERSITY
COURSE TITLE:
SEMESTER:
COURSE NUMBER:
CREDIT HOURS:
DAY & TIME:
LOCATION OF CLASS:
School Counseling Internship
INSTRUCTOR:
OFFICE LOCATION:
OFFICE PHONE:
E-MAIL ADDRESS:
OFFICE HOURS:
COURSE DESCRIPTION:
This experiential course is designed as an integrative field placement that fulfills the CACREP
requirement for clinical experiences in the School Counseling program standards. Students are
expected to engage in on-site counseling activities that allow application of the School Counseling
program curriculum content under the direction of an approved site supervisor and Xavier faculty.
COURSE OBJECTIVES:
As a result of participating in this course students will:
1. Apply previous course work from the School Counseling Program to the School Counseling
Internship Practice.
2. Utilize theories and techniques to develop professional relationships with administration,
students and families.
3. Utilize theories and techniques to develop professional relationships with other
professionals in the community.
There should be some experience in a variety of school counseling services. The degree of
involvement in these areas is naturally dependent upon the particular school site emphasis.
Sample service areas include: Testing and Assessment, Documentation, Record Keeping, Information
Services, Placement, Referral, Group Work, Consultation, Conferences, Counseling, Follow-up,
Program Planning and Evaluation.
NOTE: The total supervised internship must be no less than 600 hours of which 240 must be in direct
services.
REQUIRED TEXT:
Davis, Tamara (2005). Exploring School Counseling. Boston: Houghton—Mifflin.
INSTRUCTIONAL METHODS AND ACTIVITIES:
3
This course will utilize didactic learning methods including large and small group discussion,
individual case presentations, and role-play.
ASSIGNMENTS
1. Students are required to complete a minimum of 600 clock hours of supervised counseling
experiences in an approved school counseling setting. A minimum of 240 of these 600 hours
must be in direct service activities with clients.
2. Students will produce a log cataloging these experiences in appropriate school counseling areas
to assure some exposure to each on (i.e., testing and assessment, records management, group
work, individual counseling, consultation, resources and referral, placement, case note
procedures, evaluation, and treatment planning.
3. Students will complete an acceptable project that will be beneficial to the particular setting.
The scope of this project will be agreed upon by the college instructor, site supervisor, and the
student.
4. Students must attend scheduled on-campus seminars for progress updates. In addition to
attending the seminar meetings, students must complete other required assignments as indicated
on the schedule of classes.
5. Each student will also be responsible for developing a portfolio that can be used for
employment seeking purposes. This portfolio may contain writing samples, completed projects,
program/grant proposals, research paper, etc.
6. Students must submit a satisfactory evaluation of their performance by the site supervisor. This
evaluation will verify hours completed as well as the 1-hour face-to-face supervision for every
20 client contact hours performed by the student.
Students who have not successfully completed all internship requirements by the final class
meeting will receive an incomplete.
Students are strongly reminded of ethical considerations while enrolled in this course. Consult the
ASCA Statement of Ethics in your text for details.
**Do not hesitate to contact the instructor should you have an ethical question.
PERFORMANCE EVALUATION CRITERIA AND PROCEDURES:
Attendance/Participation
Completion of 600 hours/240 direct service hours verified by log and supervisor
Completion of site project
Completion of portfolio
Satisfactory Performance Evaluation from Internship Site Supervisor
A grade of “S” is only given if all of the above criteria are met.
ATTENDANCE POLICY:
4
Graduate students are training to be professional helpers responsible for the welfare of clients in need.
Attendance in professional counseling courses is required to evaluate the readiness and preparedness of
each student to enter the profession.
Attendance at counseling internship seminars is very important for progress updates. Attendance
means arriving for class on time and staying for the duration of the class. Participation means
preparing for class by reading required texts/materials and periodically entering into class discussion.
A student who misses more than 2 classes in a semester may be subject to possible action by the
instructor, which includes, but is not limited to:
 Recommendation to withdraw from the class.
 Additional assignments to complete the class.
 Reduction in grade per the percentage allotted to attendance and participation.
 Any other action deemed appropriate by the instructor.
Naturally, faculty members are sensitive to significant life circumstances that can result in class
absence. In such instances, faculty will attempt to work with these students on a case – by – case
basis.
Likewise, excellent attendance at the internship site is very important. Please review the “Expectations
for Xavier Interns” in your internship folder regarding this matter.
5
SCHEDULE:
Note: Additional readings may be assigned or topics may change based on the experiences of the
counseling internship students. The first half of each three hour class will be utilized for site
updates, the second half of class will be utilized for topical discussion or presentations.
Class meeting 1
Overview of Class. Introductions, Review of Syllabus/Text
Internship Placements
Review of ASCA Ethical Standards
Read: Chapter 1-2 and appendix
Class meeting 2
Therapeutic orientation of counselor in training.
Read: Chapters 3, 4, 5
Class meeting 3
Specialized topics, e.g.
NCAA Clearing House, Ohio Graduation Tests
FERPA and confidentiality
Site Project Proposal Descriptions Due
Class meeting 4
Working with diversity and special needs, IEPs, 504’s
Read: Chapter 6
**Mid-term Evaluation Due**
Class meeting 5
Counselor as Advocate, Consultant, Collaborator, and Leader
Read: Chapters 7-12
Class meeting 6
Program Planning and Evaluation: Results –Based Accountability
Read Chapter 13
Class meeting 7
School Counseling Services and Technology: Benefits & Cautions
Read : “Technology Issues” Handout
Class meeting 8
Licensure/Certification Forms and Procedures, Praxis Info,
Counselor self-care & on-going professional development
Read: Chapter 14
Final evaluation, signed logs, completed project descriptions, and
portfolio due
**Please turn off or silence all pagers and cell phones
6
XAVIER
UNIVERSITY
Department of School &
Community Counseling
3800 Victory Parkway
Cincinnati, Ohio 45207-6612
Phone (513) 745 – 3655
Fax (513) 745 – 2920
www.xavier.edu
Dear Site Supervisor,
Many thanks to you and your organization for your willingness to assist in our graduate course, COUN
670- School Counseling Internship. We value the training and insights you will be giving to the Xavier
graduate student working under your direction.
The requirements for the student to successfully complete this course are as follows:
1. Students are required to complete of a minimum of 600 clock hours of supervised counseling
experiences. A minimum of 240 of these 600 hours must be in direct service activities with clients
in an elementary, middle/junior or high school setting.
2. Students will produce a log cataloging these experiences in appropriate school counseling areas to
assure some exposure to each one (i.e., assessment/appraisal and records, group work, individual
counseling, consultation, referral, placement, etc.).
3. Students will complete an acceptable project that will be beneficial to the particular setting. The
scope to be agreed upon by the college instructor, site supervisor, and the student.
4. Students must attend seminars as scheduled on campus for progress updates.
5. Students must submit a satisfactory evaluation of performance by site supervisor. This evaluation
will verify hours completed.
A grade of “S” is only given if all of the above criteria are met.
The instructor will be contacting you during the semester to discuss the progress of our student. Please do
not hesitate to contact us at any time should you have comments, questions, or concerns.
Again, thank you for your contribution to Xavier and the helping professions.
Sincerely,
Dr. Butch Losey
Clinical Coordinator
loseyr@xavier.edu
7
SCHOOL COUNSELING INTERNSHIP
Internship Approval Request Form
This form must be filed with the Xavier University Clinical coordinator to request approval to begin the internship.
PART B: TO BE COMPLETED BY THE STUDENT
Name:
Address:
Phone: Work
Home
Semester:
Supervisor Name:
Title:
School name:
Address:
Phone:
Supervisor Degrees/certification/licenses held:
Brief Description of Expected Experiences:
Anticipated Number of Clock Hours to Be Completed at this site:
Student Signature
hrs.
Date
Approved:
, Clinical Coordinator,
(Signature)
(Date)
8
PART B: TO BE COMPLETED BY THE TRAINING SUPERVISOR
Instructions to supervisor:
After completing this form, please return it to the supervisee who is responsible for returning it
to Xavier University.
1. Are you a licensed or certified as a School Counselor?
[
] Yes [
] No
Grade Levels?
State?
2. If you are not a licensed school counselor, what license do you hold?
3. Please briefly describe the nature of the supervision to be provided:
4. Briefly describe your experience in training supervision
5. I HAVE REVIEWED THE SUPERVISEE’S STATEMENTS.
THEY (ARE
)
(ARE NOT
) ACCURATE
Supervisor’s Signature
Date
9
EXPECTATIONS FOR XAVIER INTERNS
COUN 670
1. I will at all times conduct myself in an ethical fashion in my activities with clientele and in
carrying out my duties related to my internship site. The American Counseling Association’s Code
of Ethics shall serve as a guide to my professional behavior with client and agency confidentiality
given the utmost respect.
2. I will at all times dress in professional attire appropriate to my internship site.
3. I will accurately and honestly complete logs, regularly attend on-campus class meetings, and fulfill
other assignments required as part of my internship experience.
4. I have read and am familiar with the Xavier University Affiliation Agreement (pg. 12)
5. I will meet regularly with my internship site supervisor and will follow the directions of that
individual to the best of my ability.
6. I will not hesitate to consult with my supervisor if I am concerned about my ability to provide
services to a client or if I am assigned responsibilities that seem beyond my level of professional
expertise.
7. Should a conflict, potential conflict, or other concerns arise regarding my internship activities, I
will consult with my internship site supervisor. Should this consultation fail to address my
concerns adequately, I will immediately notify my Xavier supervisor.
8. Should I choose to cease my internship activities at a particular site, I will give appropriate notice
to my supervisor and make provisions for the continued appropriate care of my clientele. In short,
I will not abandon my clients. I realize that appropriate notice will vary dependent upon my
internship activities and responsibilities.
Student Name (Please Print)
Student Signature
Date
This form should be signed and returned to the
Clinical Coordinator to include in your internship file before beginning the experience.
10
XAVIER AFFILIATION AGREEMENT AND INSTRUCTIONS
On the following pages is an Affiliation Agreement that defines the relationship between Xavier
University and your internship site.
You will note that this is a “Fill-in-the-Blank´ form that requires your supervisor’s and building
principal’s signature on the second page.
Please familiarize yourself with the terms of the Agreement and note that you are covered with liability
insurance through the University as described in Item 9.
Students are also encouraged to purchase their own liability insurance policies. An affordable policy is
available to student members of the American Counseling Association. Call 1-800-347-6647 x 284 or
visit www.counseling.org for more information.
The signed Affiliation Agreement and all other paperwork must be returned to the Xavier Clinical
Coordinator before students may begin the internship experience.
TB Testing
Some organizations will require practicum/intern students to show evidence of a recent
negative TB test.
Students can contact their physician or the Xavier Health and Counseling Center to schedule
an appointment for the test.
The Health and Counseling Center charges $15 and schedules the tests on Mondays,
Tuesdays, Wednesdays, and Fridays between the hours of 8:30 AM – 4:30 PM.
Call (513) 745- 3022 for details.
Finger-Printing/Background Checks
Likewise, some practicum/internship sites will require a background check and finger
printing.
Refer to the Attorney General’s website at http:/www.ag.state.oh.us/
or contact the BCI&I in London, Ohio at (740) 845-2375 will all fingerprinting questions.
Students are strongly encouraged to investigate specifically if the TB Test and /or the
background checks are required with the practicum/intern site before scheduling these
steps.
11
Xavier
University
COUN 670
GRADUATE COUNSELING INTERNSHIP AFFILIATION AGREEMENT
BETWEEN
SITE:
AND
XAVIER UNIVERSITY, Cincinnati, OH
This agreement is entered into this
day of
, 20
, by and between
Xavier University (hereinafter “University” and
, (hereinafter
“Facility”) for the purpose of providing Counseling Internship Experiences for
, a Graduate Counseling student at the University.
Both parties recognize the need for counseling experiences at sites providing assistance to clients
needing a wide range of services. The purpose of these experiences is to provide Graduate Counseling
students opportunities for extended observation and participation, with the understanding that these
experiences will be integrated with course work within the Graduate Counseling Program curriculum.
In order to accomplish this purpose, the following practices will be observed:
1.
The University will be responsible for establishing objectives for the experiences, and for
providing these to the Facility.
2.
The University will schedule the student for these experiences in collaboration with the Facility
and consistent with accepted non-discriminatory practices.
3.
The Facility will provide supervision of the student on site by qualified, competent, and
appropriately credentialed personnel; these persons will be designated as “on-site supervisors.”
4.
The University will provide the student with information regarding expectations for the
experiences and with general instruction in information needed to participate in these experiences.
5.
On-site supervisors will provide the student additional instruction as needed for the student to
perform specific assigned tasks.
6.
The University will provide the on-site supervisor with forms to be used in evaluating student
performance. Supervisors will complete the forms and return them to the University, to be used in
assigning the student grades for the experiences.
7.
The Facility will hold itself available at all reasonable times, as designated by the University in
consultation with the Facility, for the Internship experiences of the Graduate Counseling student
of the University.
8.
The University (including both faculty and student) agrees to respect the confidentiality of the
clients of the Facility.
12
9.
The University shall provide evidence of professional liability insurance coverage in the amount
of $2,000,000/$4,000,000 for all its students, employees and agents who are assigned supervisory
or administrative duties in the Facility in connection with the affiliation of the University’s
students.
This agreement will be deemed in effect indefinitely unless one or both parties submit 30 days written
notice for cancellation. In the event of cancellation, both parties will observe all obligations under the
agreement until the end of the University’s academic semester during which cancellation occurs.
The signatures below attest to agreement to abide by the described practices:
________________________________________________
Site Supervisor
Date
Site Supervisor Information:
Phone number__________________
Print Name_______________________________________
Email_________________________
Supervisor Credentials______________________________
Dr. Butch Losey, Ed.D., PCC-S, NCC
Clinical Coordinator
Department of Counseling
Xavier University
Date
Dr. Scott A. Chadwick
Date
Provost and Chief Academic Officer
Xavier University
13
TYPE KEY:
Class Meetings = CM
Supervision = S
Documentation = DOC
Other = O
DS = Individual, Family Conferences, Group
Cons = Consultation with Faculty, etc.
A/T = Assessment/Testing
COUN 670 - COUNSELING INTERNSHIP LOG
Name:
SS #:
Date:
Placement Site:
Site Supervisor:
Do not include confidential information (e.g. client names) on this log!
DATE
ACTIVITY
TIME (in clock hours)
TYPE

Please total hours for each type of service for each page:
DS:
S:
_____
CM: _____ O: _____ _
Cons:______ DOC:
A/T: _____
Total of all types:
14
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
S:
CM:
O:
Cons: _____ DOC: _____
A/T: ______
Total of all types:
15
DATE
ACTIVITY
TYPE
TIME (in clock hours)

Please total hours for each type of service for each page:
DS:
S:
CM:
O:
Cons: _____ DOC: _____
A/T: ______
Total of all types:
16
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
S:
CM:
O:
Cons: ______DOC: ___
A/T:_____
Total of all types:

Please total hours for each type of service for each page:
17
DS:
CM:
S:
O:
DATE
ACTIVITY
TYPE
TIME (in clock hours)
Cons:_____ DOC: ______
A/T: _______
Total of all types:
18
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
S:
CM:
O:
Cons:_____ DOC: _____
A/T: _______
Total of all types:
19
DATE
ACTIVITY
TYPE
Please total hours for each type of service for each page:
TIME (in clock hours)
DS:
CM:
Cons:
A/T:
Total of all types:
20
S:
O:
DOC:
DATE
ACTIVITY
TYPE
TIME (in clock hours)


Please total hours for each type of service for each page:
DS:
CM:
Cons:
A/T:
Total of all types:

21
S:
O:
DOC:
DATE
ACTIVITY
TYPE
TIME (in clock hours)

TOTAL - DS:
S:
CM:
O:
DOC:
Cons: _____ A/T:
___
= _________grand total hrs.
We certify that the above information is accurate and complete.
Signature of Student
Date
Signature of Site Supervisor
Date
22
Field Project Information
The Counseling Internship requires the completion of a project that will be useful to the placement site.
Ideas for the project should be discussed with the supervisor and then submitted to the Xavier Clinical
Coordinator for approval. The form on the following page is to be used to submit the proposal.
Xavier approval of the project is necessary to insure that the activities are appropriate for the intern and
contribute to learning. Also, projects that are excessive in their scope and/or time demands can be
avoided.
When the project is complete, students are asked to submit a 1-2 page summary of the project. This
summary should include a brief rationale for the project, a summary of the project activities, and
results of the effort.
Hours spent on the project can be logged toward the 600-clock hour requirement.
Possible Site Projects:
 Update community referral resource manual.
 Develop the curriculum for a psychoeducational group.
 Develop, implement, and evaluate a group.
 Research the different scheduling options.
 Research and write a grant for the school to secure funding for a specific project.
23
Field Site Project Description
COUN 670
Name:
Address:
Phone:
Field Placement:
Institution Name:
Address:
Phone:
Brief description of project:
Rationale for the project:
Supervisor Authorization of Project:
(Signature)
24
Requesting an Extension from Clinical Coordinator
Internship requires a completion of 600 clock hours which students sometimes may not complete in
one semester. Therefore, an extension can be requested for an addition 30 days beyond the semester
end. Please request this from the Clinical Coordinator. If a request is not made for the extension and
the student needs more time to complete the hours, the student will be expected to register for and
additional semester of internship class and attend all class sessions.
SUMMER INTERNSHIP
Students can apply for summer internship (Applying does not mean that the request will automatically
be granted). The decision to grant summer internship will depend on the student’s need and number of
students applying. The summer internship option is only available to students continuing their
placement from the spring semester or starting early to participate in activities such as individualized
or group work with students, scheduling, or staff training. Students will be required to register and
attend classes that are offered June 15th through July 15th. If all of the Summer Internship Criteria
below are met, you can apply using the application form on the next page.
Summer Internship Criteria:
1. You were enrolled in the spring session OR your site has requested that you start early for a
specific reason.
2. You will not be completing all your internship hours in the summer term.
3. Your supervisor will be at the site and available.
4. You will have a regular schedule and will not be working from home.
25
Application for Summer Internship
Date Submitted_______________________________________________
Student Name________________________________________________
Site_______________________________________________________
Site Supervisor_______________________________________________
Do all of the following apply to your request?
[ ] You were enrolled in the spring session OR your site has requested that you start early for
a specific reason. If an early start is requested, you plan to be enrolled in the fall semester.
[ ] You will not be completing all your internship hours in the summer term.
[ ] Your supervisor will be at the site and available.
[ ] You will have a regular schedule and will not be working from home.
Reason for applying for Summer Internship (use additional paper as needed):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
________________________________________
Signature
Date
26
XAVIER
UNIVERSITY
Department of School &
Community Counseling
3800 Victory Parkway
Cincinnati, Ohio 45207-6612
Phone (513) 745 – 3655
Fax (513) 745 – 2920
Date :
To:
______________________________________________________
From:
______________________________________________________
Subject: Internship
I will not be completing my School Internship experience by the end of the semester. I am
requesting an extension to continue my Internship experience.
Name __________________________________________________________
Email Address ____________________________________________________
Daytime Phone # ___________________________________________________
Cell Phone #
_____________________________________________________
Internship Placement ________________________________________________
Total hours completed to date ___________________________________________
Expected date of completion ____________________________________________
Please return to:
Dr. Butch Losey
Clinical Coordinator
3800 Victory Parkway
Cincinnati, Ohio 45207-6612
Office: (513) 745-3450
Fax: (513) 745-2920
***Please copy for your records
27
Student Evaluation Procedures
Grading for the Internship Course is on a “Satisfactory/Unsatisfactory” basis.
To earn a “S” grade, students must:
 Attend and participate at on-campus class sessions.
 File all forms and other required paperwork by course deadlines.
 Consistently adhere to ethical considerations and demonstrate professional responsibility to the
internship site.
 Consistently demonstrate an openness to supervisor critique and a willingness to learn.
Student progress in the internship experience is monitored in several ways. These may include:
 Clinical Coordinator visits to discuss student progress with the site supervisor.
 Telephone consultations with site supervisors.
 Site Supervisor completion of the Interim Evaluation From (see next page).
 Site Supervisor completion of the Final School Counseling Internship Supervisor Evaluation
Rating Form (see pp. 25-28).
The original of this form must be filed with the Xavier clinical Coordinator at the successful
completion of the internship to serve as the final student evaluation.
Please note that all supervisors must complete this form during the internship. That is, if a student
changes internship sites or supervision during the experience, an Evaluation Form must be completed
by each supervisor.
28
Interim Evaluation Form
Supervisor Name:
Intern Name:
Supervisor Signature:
Address:
Phone:
Date:
EXCEEDS
At present the intern under my supervision:
MEETS
Has an awareness of his/her own strengths and
limitations
Uses supervision for personal and professional
2.
growth
Hears and understands the supervisor’s feedback
3. during supervision
Openly and appropriately communicates with the
4.
supervisor
5. Readily seeks supervisory direction when needed
6. Initiates appropriate working relationships with
clients
Follows ethical procedures (e.g. confidentiality) in
7. client relationships and in regard to organizational
issues
8. Is able to define appropriate counseling goals with
clients
9. Is accepting of client differences
Can articulate and provide a rational for treatment
10.
approaches
11. Keeps all required records up to date
1.
OVERALL:
12. Is successfully fulfilling internship responsibilities
13. I have a concern, please contact me to discuss
Return to: Dr. Rhonda L. Norman
3800 Victory Parkway
Cincinnati, Ohio 45207-6612
(513) 745-3450
(513) 745-2920 – fax
29
Return by:
BELOW
N/A
FINAL INTERN EVALUATION: SUPERVISOR FORM
Intern Name:
Date of Evaluation:
/
/
Supervisor:
Internship Site:
Instructions: This form is designed to help supervisors provide feedback about the performance of
interns at the completion of their experience. This form will become part of the intern’s record for this
course and will be considered in assigning grades for the internship. Please answer each item using the
scale provided. Space is provided following each category group for specific comments. There is also
space at the end of this form for general comments. If you feel it would be helpful to put anything into
context from the outset, please feel free to do so below.
Initial Comments:
Answer Code for Evaluation Items and Questions
NA. Not Applicable or not enough information to form a judgment
1. Far Below Expectations – needs much improvement, a concern
2. Below Expectations – needs some improvement to meet standards
3. Acceptable – meets standards at average level for interns
4. Above Expectations – performs above average level for interns
5. Far Above Expectations – a definite strength, performs well beyond average levels for interns
I.
Basic Work Requirements
a. Arrives on time consistently
b. Uses time effectively
c. Informs supervisor and makes arrangements for absences
d. Reliably completes requested or assigned tasks on time
e. Completes required total number of hours or days on site
f. Is responsive to norms about clothing, language, etc., on site
Comments:
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II.
Ethical Awareness and Conduct
a. Knowledge of general ethical guidelines
b. Knowledge of ethical guidelines of internship placement
c. Demonstrates awareness and sensitivity to ethical issues
d. Personal behavior is consistent with ethical guidelines
e. Consults with others about ethical issues if necessary
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Comments:
III.
Knowledge and Learning
a. Knowledge of Client Population
1. Knowledge level of client population at beginning of internship 1
2
2. Knowledge level of client population at end of internship
1
2
b. Knowledge of Appropriate Counseling Approaches
1. Knowledge of appropriate counseling approaches at beginning of internship
1
2
2. Knowledge of appropriate counseling approaches at end of internship
1
2
c. Leaning
1. Receptive to learning when new information is offered
1
2
2. Actively seeks new information from staff or supervisor
1
2
3. Ability to learn and understand new information
1
2
4. Understanding of concepts, theories, and information
1
2
5. Ability to apply new information in school counseling setting
1
2
Comments:
IV.
Response to Supervision
a. Actively seeks supervision when necessary
b. Receptive to feedback and suggestions from supervisor
c. Understands information communicated in supervision
d. Successfully implements suggestions from supervisor
e. Aware of areas that need improvement
f. Willingness to explore personal strengths and weaknesses
Comments:
V.
Interactions with Clients
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1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
a.
b.
c.
d.
e.
f.
g.
Appears comfortable interacting with clients
Initiates interactions with clients
Communicates effectively with clients
Builds rapport and respect with clients
Is sensitive and responsive to client’s needs
Is sensitive to cultural differences
Is sensitive to issues of gender differences
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
5
5
5
5
5
5
5
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
5
5
5
5
5
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
Comments:
Suggested areas for further study:
VI.
Interactions with Coworkers
a. Appears comfortable interacting with other staff members
b. Initiates interactions with staff
c. Communicates effectively with staff
d. Effectively conveys information and expresses own opinions
e. Effectively receives information and opinions from others
Comments:
VII.
Work Products
a. Reliably and accurately keeps records
b. Written or verbal reports are accurate and factually correct
c. Written or verbal reports are presented in professional manner
d. Reports are clinically or administratively useful
Comments:
Overall, what would you identify as this intern’s strong points?
What would you identify as areas in which this intern should improve?
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Would you recommend this intern for school counselor certification/licensure?
Yes
Yes, with reservations
No
If ‘yes, with reservations’ or ‘no’, please explain:
Supervisor’s Signature:
Date:
Thank you for your time in supervising this intern and in completing this evaluation.
Questions/Concerns?
Contact: Dr. Butch Losey
Clinical Coordinator
Xavier University
(513) 745-1037
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Confidential Internship Site Evaluation Form
Intern’s Name
______________________________________________________________
Date of Evaluation _______ Name of School ______________________________
School Supervisor _____________________ Title & license __________________
Internship dates ________________ to _________________ Total # hours ______
Complete this form when you complete your internship. If you have multiple sites please
submit an evaluation form for each location.
THE SITE
4 = Outstanding
1.
2.
3.
4.
5.
6.
7.
8.
3 = Good
2 = Fair
1 = Poor
Overall school operations and administration
Introduction to school mission and structure
Awareness of roles of administrative staff
Knowledge of school goals
Understanding of policies and procedures
Policies on risk management (including duty to warn)
Policies on confidentiality of records
Policies regarding maintenance of records
NA = Not Applicable
__________
__________
__________
__________
__________
__________
__________
__________
Comments:
THE SUPERVISOR
4 = Outstanding
3 = Good
2 = Fair
1 = Poor
NA = Not Applicable
Please rate your supervisor’s ability to assess/develop you in these areas.
1. Communication skills
2. Assessment/Appraisal
3. Program Planning
4. Case management
5. School operations and administration
6. Professional orientation
7. Knowledge and application of professional ethics
8. Ability to process my professional issues with supervisor
9. Group Work
10. Counseling
11. Consultation
12. Referral
Comments:
34
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________