Evaluation of Practicum Student by Supervisor
Practicum Site: ______________________________________________________________
Student: ___________________________________________________________________
Supervisor(s): _______________________________________________________________
Time Period: from _________________________ through ___________________________
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.
Check the appropriate box 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 –
Superior
Good
Average
Below Average
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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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. Write-in additional instruments not listed:
Not Exposed
Observed
Administered
Proficient
Not Exposed
WAIS
WMS
WISC
Bender-Gestalt
WPPSI
Observed
Administered
Trails A & B
Structured Diagnostic Interview
Stanford-Binet
(e.g., SCID, SADS, DIS, DISC)
Shipley
MMPI
Vineland
MCMI
WRAT
PAI
PPVT
TAT
Child Behavior Checklists
CAT/RATC
Connors Scales
Sentence Completion
Rorschach, scoring system
Strong Interest Inventory
_____________________
Projective Drawings
Myers-Briggs
(e.g., DAP, HTP)
RESEARCH –
not applicable
Superior
Good
Average
Below Average
Background and Understanding
Methodology and Design
Ability to Carry Out
Research Topic: ________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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Proficient
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.)
(circle one)
This evaluation has / has not been discussed by the supervisor and student:
Signature of Supervisor
Date
Signature of Student
Date
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