Evaluation of Practicum Student by Supervisor
Practicum Site:
Student:
Supervisor(s):
Time Period: from mm-dd-yy through mm-dd-yy
Please fill out this evaluation form to summarize your supervision of the above student. Indicate “not
applicable for those areas which do not apply to your involvement with this student. Please rate the student
in comparison to other students at his/her level of training. Comments are very helpful.
Click on the appropriate checkbox for each item:
Ability to establish rapport & relate effectively to patients
Degree of skill in interviewing
Knowledge of relevant psychological literature & ability to
utilize in clinical activities
Ability to understand patients’ psychological functioning via
observations, interviews & test results
Ability to communicate clinical data via verbal report
Ability to communicate clinical data via written data
Ability to benefit from supervision by accepting correction
Sensitivity to ethical issues
Sensitivity to diversity issues
Ability to benefit from supervision by NOT being overly
dependent on supervisor’s formulations
Ability to work effectively with staff and students
Dependability and efficiency in completing reports, etc. in
reasonable time.
Promptness in meeting appointments, etc.
PSYCHOTHERAPY –
not applicable
Number and type(s) of clients/patients seen:
Type(s) of Therapy:
GROUP THERAPY –
not applicable
Number and type(s) of clients/patients seen:
Type(s) of Therapy:
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Revision Date: 12.06.05
Superior
Good
Average
Below Average
Evaluation of Practicum Student by Supervisor
DIAGNOSTIC TESTING –
not applicable
Superior
Good
Average
Below Average
Administration and Scoring
Interpretation
Number and type(s) of clients/patients assessed:
Please indicate the tests with which the student has gained experience:
Not Exposed WAIS
Not Exposed Child Behavior Checklists
Not Exposed MMPI
Not Exposed WISC
Not Exposed Connors Scales
Not Exposed MCMI
Not Exposed WPPSI
Not Exposed Strong Interest Inventory
Not Exposed PAI
Not Exposed Stanford-Binet
Not Exposed Myers-Briggs
Not Exposed TAT
Not Exposed Shipley
Not Exposed WMS
Not Exposed CAT/RATC
Not Exposed Vineland
Not Exposed Bender-Gestalt
Not Exposed Sentence Completion
Not Exposed WRAT
Not Exposed Trails A & B
Not Exposed Rorschach scoring system used
Not Exposed PPVT
Not Exposed Structured Diagnostic Interview
(e.g., SCID, SADS, DIS, DISC)
Not Exposed Projective Drawings
(e.g., DAP, HTP)
Others (specify):
Not Exposed
Not Exposed
Not Exposed
Not Exposed
Not Exposed
Not Exposed
Not Exposed
Not Exposed
Not Exposed
Not Exposed
Not Exposed
Not Exposed
RESEARCH –
not applicable
Superior
Background and Understanding
Methodology and Design
Ability to Carry Out
Research Topic:
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Revision Date: 12.06.05
Good
Average
Below Average
Evaluation of Practicum Student by Supervisor
IMPORTANT – Please discuss the following:

General summary of student’s current level of professional development, including particular strengths
and weaknesses.

Any special activities or projects participated in or initiated by the student.

Recommendations for further training (e.g., areas for special emphasis, supervisory problems and
suggested approach).

Distinguishing personality characteristics of student, especially as they relate to professional
functioning.
During the time period stated at the top of this form, this student has completed the following practicum
hours under my supervision:
Total Direct Service Intervention and Assessment Hours (Actual clock hours in direct service to
clients/patients – a 45-50 min client/patient hour may be counted as one practicum hour. 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 below.)
Total Clinically Related Support Hours (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, didactic training such as grand rounds and seminars)
Total Supervision Hours
Grade Earned (You should assign any letter grade you feel best represents this student’s
performance, as a method of evaluation and communication with the student. This grade will not be
registered on the student’s transcript. The DCT will use your overall evaluation to assign an official
university grade of Credit (pass) or No Credit (fail) for the student. As a general guide, a grade of C or
lower in a graduate course is considered unsatisfactory.)
This evaluation drop down menu been discussed by the supervisor and student:
Signature of Supervisor
Date
Signature of Student
Date
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Revision Date: 12.06.05