FACULTY SUPERVISOR’S EVALUATION OF INTERN STUDENT
Student’s Name ____________________________
Faculty Supervisor _________________________
Agency/School_____________________________
Level of Effectiveness
1. Pre-practicum
2. Early practicum
3. Late practicum
Date ______________________________________
4. Early Internship
5. Late Internship
NA/? Not applicable/
Unknown
Note: Specific dimensions of some of these competencies are incorporated on the Faculty Supervisor’s Evaluation of
Practicum Student form.
The intern has demonstrated the following competencies while working at this site to the degree indicated:
1.
2.
Direct Client Service
Level
a) Clarifies counselor/client expectations
1
2
3
4
5
NA/?
b) Conducts the interview so as to promote
positive outcomes
1
2
3
4
5
NA/?
c) Formulates plausible hypothesis about the
client’s situation
1
2
3
4
5
NA/?
d) Terminates the counseling relationship
effectively
1
2
3
4
5
NA/?
e) Performs group counseling skills effectively
1
2
3
4
5
NA/?
f) Demonstrates sufficient progress toward
professional identity development
1
2
3
4
5
NA/?
g) Complies with school/agency policies and
procedures
1
2
3
4
5
NA/?
h) Communicates effectively with others on
professional matters
1
2
3
4
5
NA/?
a) Writes clear, accurate reports on clients
1
2
3
4
5
NA/?
b) Performs psychoeducational activities such
as outreach, conferences, instruction, etc.
1
2
3
4
5
NA/?
c) Assumes responsibility for a client in so far
as it is allowed
1
2
3
4
5
NA/?
Indirect Client Service
3.
d) Takes the initiative when the situation
requires such action
1
2
3
4
5
NA/?
e) Assimilates and uses supervisory feedback
1
2
3
4
5
NA/?
f) Functions as a team member of this
organization
1
2
3
4
5
NA/?
General Comments
a) What are the intern’s strengths? (e.g., personality characteristics, motivation, etc.)
b) How would you describe the quality of the intern’s professional development over the
past term?
c) What suggestions, if any, do you care to make?
Signature ______________________________________
Faculty Supervisor
Date ___________________________
Rev. 07/09