Evaluation of Practicum Site by Student
This form is to be completed by the practicum student and given to the Program Director at the
conclusion of each semester of practicum.
Student Name:
Date:
Site:
Semester:
Supervisor(s):
Year:
PART I. CLINICAL EXPERIENCE AT THIS SITE
Using the AAPI format provided, enter information about the experiences you gained at this specific site this semester.
A practicum hour is a clock hour, not a semester hour. A 45-50 minute client/patient hour may be counted as one practicum hour. A
practicum hour should not be counted more than once. You may have some experiences that could potentially fall under more than
one category, but it is your responsibility to select the category that you feel best captures the experience. (For example, a Stress
Management group might be classified as a group or as a Medical / Health-Related Intervention, but not both.)
*PROVIDE INFORMATION ONLY ABOUT YOUR CLINICAL ACTIVITIES AT THIS SITE DURING THIS SEMESTER.
1.
DIRECT SERVICE – Please tell us about your intervention and assessment experiences at this site using the categories below.
Please report actual clock hours in direct service to clients / patients. Time spent gathering information about the client / patient, but not in
the actual presence of the client / patient, should instead be recorded under “Support Activities”. For the “Total hours face-to-face”
columns, count each hour of a group, family, or couples session as one practicum hour. For example, a two-hour group session with 12
adults is counted as two hours. For the “# of different...” columns, count a couple, family, or group as one (1) unit. For example, meeting
with a group of 12 adults over a ten-week period counts as one (1) group. Groups may be closed or open membership; but, in either case,
count the group as one group.
a. Individual Therapy
1) Older Adults (65+)
2) Adults (18-64)
3) Adolescents (13-17)
4) School-Age (6-12)
5) Pre-School Age (3-5)
6) Infants / Toddlers (0-2)
b. Career Counseling
1) Adults
2) Adolescents
c. Group Counseling
1) Adults
2) Adolescents (13-17)
3) Children (12 and under)
d. Family Therapy
Total hours face-to-face
# of different individuals
Total hours face-to-face
# of different individuals
Total hours face-to-face
# of different groups
Total hours face-to-face
# of different families
e. Couples Therapy
Total hours face-to-face
# of different couples
f. School Counseling Interventions
1) Consultation
2) Direct Intervention
3) Other:
g. Other Psychological Interventions
1) Sports Psychology / Performance Enhancement
2) Medical / Health – Related Interventions
3) Intake Interview / Structured Interview
4) Substance Abuse Interventions
5) Other Interventions (e.g. milieu therapy,
treatment planning with the patient present.)
Please describe the nature of the experience in g5:
Total hours face-to-face
# of different individuals
Total hours face-to-face
# of different individuals
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Evaluation of Practicum Site by Student
h. Psychological Assessment Experience: This is the estimated total number of face-to-face client contact hours administering and providing
feedback to clients/patients. This does not include time spent scoring and/or report writing, which should be included under “Support
Activities”. You will provide information about numbers of specific tests administered in a later section.
Total hours face-to-face
1)
Psychodiagnostic test administration (Include symptom assessment,
projectives, personality, objective measures, achievement, intelligence,
and career assessment), and providing feedback to clients/patients.
2)
Neuropsychological Assessment (Include intellectual assessment in this category
only when it was administered in the context of neuropsychological assessment
involving evaluation of multiple cognitive, sensory and motor functions).
3)
Other:
(Specify :
)
i. Other Psychological Experience with Students and/or Organizations:
1)
Total hours face-to-face
Supervision of other students performing intervention and assessment activities
2)
Program Development/Outreach Programming
3)
Outcome Assessment of programs or projects
4)
Systems Intervention / Organizational Consultation / Performance Improvement
5)
Other
(Specify :
)
TOTAL DIRECT SERVICE:
Add the number of hours included in 1a through 1i above
Total Face-to-Face Intervention & Assessment Hours:
2.
SUPPORT ACTIVITIES – How much time have you spent in support activities related to your intervention and assessment
experience? This item includes activities spent outside the counseling / therapy hour while still focused on the client / patient (e.g. chart
review, writing process notes, consulting with other professionals about cases, video / audio tape review, time spent planning interventions,
assessment interpretation and report writing, etc.). In addition, it includes hours spent at a practicum setting in didactic training (e.g. grand
rounds, seminars).
Total Support Hours:
3.
SUPERVISION RECEIVED – How much time have you spent in supervision? Supervision is divided into one-to-one, group, and peer
supervision / consultation. Supervision you provided to less advanced students should be counted in item 1i above.
Item 3a: Hours are defined as regularly scheduled, face-to-face individual supervision with specific intent of overseeing the psychological
services rendered by the student.
Items 3b and 3c: The hours recorded in the group supervision category should be actual hours of group focus on specific cases. Many
excellent practicum courses incorporate both didactic and experiential components in the course activity. While the didactic portion is
excellent training, it should not be recorded as a supervision activity; it should instead be included as a support activity in “Support
Activities” above. This may necessitate breaking the hours spent in a practicum course into intervention, supervision, and didactic
activities by actual course hours. For example, if you present on the “Psychosocial Issues of HIV Infection” using examples of cases, it is a
didactic activity. Similarly, Grand Rounds that consists of in-service education on specific topics would not be considered supervision for
the purposes of documenting practicum hours, but would be considered a support activity.
Total hours
a.
Hours spent in one-on-one, face-to-face supervision:
b.
Hours spent in group supervision:
c.
Hours of peer supervision / consultation
and case discussion on specific cases:
Total Supervision Hours (add 3a, 3b, and 3c):
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Evaluation of Practicum Site by Student
4.
PATIENT/CLIENT DIVERSITY – Please indicate the number of clients/patients in each of the following categories:
Race/ethnicity
Number of Different clients/patients seen
Intervention
Assessment
African-American / Black / African Origin
Asian-American / Asian Origin / Pacific Islander
Latino-a / Hispanic
American Indian / Alaska Native / Aboriginal Canadian
European Origin / White
Bi-racial / Multi-racial
Other (Specify:
)
SEXUAL ORIENTATION (Please indicate only for those clients where
this information is known.)
Number of Different clients/patients seen
Intervention
Heterosexual
Gay
Lesbian
Bisexual
Other (Specify:
Assessment
)
DISABILITIES
Number of Different clients/patients seen
Intervention
Assessment
Physical / Orthopedic Disability
Blind / Visually Impaired
Deaf / Hard of Hearing
Learning / Cognitive Disability
Developmental Disability (Including Mental Retardation and Autism)
Serious Mental Illness (e.g., primary psychotic disorders, major mood
disorders that significantly interfere with adaptive functioning)
Other (Specify:
)
GENDER
Number of Different clients/patients seen
Intervention
Assessment
Male
Female
Transgendered
Comments:
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5.
TEST ADMINISTRATION – What is your experience with the following instruments? Indicate all instruments used by you in your
assessment experience, excluding practice administrations to fellow students. Indicate the number of tests that you administered and scored
in the first column. In the second column, indicate how many of those that you administered and scored in column one were subsequently
interpreted in a report that you wrote. Designate your experiences for the instruments listed below, without changing the sequence in which
they are listed. Then, you may add up to 10 additional instruments (under “Other Tests”) for any other tests that you have administered.
ADULT TESTS
Bender Gestalt
Millon Clinical Multi-Axial Inv. III (MCMI)
MMPI-II
Myers-Briggs Type Indicator
Personality Assessment Inventory
Projective Sentences (includes Rotter Sentence Completion and other Sentence Completion Tests)
Projective Drawings (includes Draw-a-Person Test and Kinetic Family Drawing Test)
Rorschach -- scoring system:
Self-report measures of symptoms / disorders (e.g., Beck Depression Inventory)
Strong Interest Inventory
Structured Diagnostic Interviews (e.g., SADS, DIS)
TAT
Trail Making Test A & B
WAIS
Wechsler Memory Scale
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
CHILD AND ADOLESCENT TESTS
Connors Scales (ADD assessment)
Diagnostic Interviews (e.g., DISC, Kiddie-SADS)
MMPI-A
Parent Report Measures (e.g., Child Behavior Checklist)
Peabody Picture Vocabulary Test
Rorschach (scoring system:
)
Self report measures of symptoms / disorders (e.g., Children’s Depression Inventory)
WISC
WPPSI
WRAT
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
Other Tests (Specify:
)
6.
# ADMINISTERED AND SCORED
# OF REPORTS WRITTEN
# ADMNISTERED AND SCORED
# OF REPORTS WRITTEN
INTEGRATED REPORT WRITING -- How many supervised integrated psychological reports have you written for each of the
following populations? An integrated report includes a history, an interview, and at least two tests from one or more of the following
categories: personality assessments (objective and/or projective), intellectual assessment, cognitive assessment, and/or neuropsychological
assessment. These are synthesized into a comprehensive report providing an overall picture of the patient/client.
# Integrated reports
Integrated Report Writing
a. Adults
b. Children/Adolescents
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PART II. DIDACTIC INSTRUCTION AT THIS SITE
Indicate hours and nature of didactic instruction (in-service training, grand rounds, case seminars, speakers, etc.) at
this site. See sample entries in the table below.
Date & Hours
5/01, 1.5 hrs
9/01, 1 hr
Didactic Activity
Grand Rounds
Case Seminar
Instructor & Topic
Dr. Important Person, Assessment of XYZ in a special population
Dr. Very Important Person, Treatment of ABC
PART III. DISCUSSION OF ETHICAL PRINCIPLES AT THIS SITE
Please check all topics discussed during your placement at this site. Specify the context (e.g., was the topic discussed in individual supervision?
At grand rounds? In a case conference? etc.)
Check all that apply:
Process of ethical decision making
Advertising and public statements
Privacy and confidentiality
Resolving ethical issues
Practice informed by science
Dual relationships and conflicts of interests
Limits of competence
Crisis intervention
Multicultural sensitivity (e.g., awareness of personal values,
Context:
understanding the world view of the client, developing appropriate
assessment/treatment strategies and techniques)
competence and appropriate use of assessments and interventions
informed consent
record keeping
terminating professional relationships
ethical issues surrounding research and publishing
other (specify)
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Evaluation of Practicum Site by Student
PART IV. SITE EVALUATION
1.
What were the strengths of this site and supervisor(s)?
2.
What areas need improvement?
3.
How well did this practicum experience meet your training goals and interests? Drop-down menu
If less than adequate (3), please explain.
4.
How would you rate the quality and quantity of the feedback you received from your supervisor(s)? Drop-down menu
If less than adequate (3), please explain.
5.
Overall how satisfied were you with your training in each of the following areas?
Assessment Drop-down menu
If less than 3, please explain.
Intervention Drop-down menu
If less than 3, please explain.
Ethics Drop-down menu
If less than 3, please explain.
6. How would you rate the overall quality of your experience at this site? Drop-down menu
If less than adequate (3), please explain.
7.
(Optional) Additional Comments:
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