EVALUATION of INDIVIDUAL CLINICAL PRACTICE
(Of Psychology Interns By Primary Individual Clinical Supervisor)
Supervisee: ___________________________
Supervisor: _____________________________
Rater:
Semester: ____________________________
Self ___
Supervisor ___
The purpose of this evaluation is to provide the trainee therapist with feedback regarding his/her performance in
their individual clinical work, including individual psychotherapy, clinical assessment interviews, integration of
psychological testing, and crisis intervention, as well as more global areas of professional competence, including
ethical and professional behavior, multicultural awareness, and self-awareness.
Please use the scale provided below to honestly evaluate the level of trainee functioning in each of the items listed
below. Please provide additional narrative feedback as appropriate/necessary.
Intern Performance Rating Scale
1 = Performs inadequately for an intern in this area. Requires frequent and close supervision and monitoring of
basic and advanced tasks in this area.
2 = Requires supervision and monitoring in carrying out routine tasks in this area and requires significant
supervision and close monitoring in carrying out advanced tasks in this area.
3 = Requires some supervision and monitoring in carrying out routine tasks in this area. Requires guidance,
training, education, and ongoing supervision for developing advanced skills in this area.
4 = Displays mastery of routine tasks in this area. Requires ongoing supervision for performance of advanced skills
in this area. The intern occasionally, spontaneously demonstrates advanced skills in this area.
5 = Displays mastery of routine tasks in this area. Requires periodic supervision for refinement of advanced skills
in this area.
6 = Displays mastery of routine tasks in this area. Could continue to benefit from some supervision on advanced
and/or non-routine tasks in this area.
7 = Performs at the independent practice level in this area and is capable of teaching others in this area. Performs
without the general need of supervision but consults when appropriate.
NA = Not Applicable/Not enough information to adequately evaluate performance
CONCEPTUALIZATION
OVERALL RATING 1 2 3 4 5 6 7 NA
1. integrates theory with clinical/client data to formulate coherent, sophisticated, and
helpful case conceptualizations and diagnostic impressions
2. integrates multicultural/diversity issues in client case conceptualizations
3. clearly communicates case conceptualizations verbally and in writing
4. uses conceptualizations to inform treatment planning & interventions
1 2 3 4 5 6 7 NA
THERAPY RELATIONSHIP & TECHNIQUE
1 2 3 4 5 6 7 NA
1.
2.
3.
4.
5.
OVERALL RATING
establishes good rapport and working alliance with a wide range of clients
demonstrates empathy with a wide range of clients
establishes and maintains appropriate therapeutic boundaries
demonstrates flexibility to receive and work with client feedback
appropriately identifies short and long-term treatment goals and selects interventions
accordingly
6. attends to issues of timing/pacing of interventions
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1
1
1
1
1
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2
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2
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3
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4
4
4
5
5
5
5
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6
6
6
6
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7
7
7
7
NA
NA
NA
NA
NA
1 2 3 4 5 6 7 NA
7. deliberately selects interventions based on sound clinical rationale and clients’ needs
and capacities
8. attends to and works with client resistance
9. attends to and uses the therapeutic relationship as an intervention tool (including but
not limited to transference/counter-tranference, therapist self-disclosure, parallel
interpersonal dynamics played out in the therapy relationship)
10. demonstrates sensitivity to multicultural issues in the therapy relationship and in
formulating and implementing interventions
11. attends to termination issues in a timely and integrated manner
12. assesses the impact of treatment/interventions and makes appropriate adjustments
1 2 3 4 5 6 7 NA
INITIAL ASSESSMENT & TESTING
1 2 3 4 5 6 7 NA
OVERALL RATING
1. demonstrates knowledge and skills in clinical interviewing
2. gathers adequate information to formulate solid initial clinical impressions and
determine appropriate treatment recommendations
3. demonstrates awareness of multicultural/diversity issues in assessment
4. selects appropriate assessment instruments for intended purpose of the assessment
5. appropriately integrates assessment/test results into therapy
6. written reports for assessment/testing are clear and comprehensive
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1
1
1
1
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2
2
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3
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4
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4
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5
5
5
5
6
6
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7
7
7
7
NA
NA
NA
NA
(Please see Assessment Coordinator’s Summary Evaluations for more detailed description
of intern’s performance on Psychological Assessment and Testing)
OVERALL RATING
1 2 3 4 5 6 7 NA
1. conducts thorough crisis and lethality assessments
2. demonstrates good clinical judgment in selecting and implementing appropriate crisis
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
intervention strategies (e.g. follow-up, safety contracts, voluntary or involuntary
transport to hospital for further evaluation)
3. consults with other staff/professionals as appropriate/necessary
4. clearly and promptly documents crisis assessments and interventions
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
MENTAL HEALTH CONSULTATION
1 2 3 4 5 6 7 NA
CRISIS INTERVENTION
OVERALL RATING
1. accurately assesses consultee’s needs, expectations, resources, capacities, and
motivation
2. establishes and communicates reasonable goals and expectations to consultee
3. adequately responds to the needs of the consultee
4. demonstrates sensitivity to diversity and multicultural issues as they may impact the
consultation contact or relationship
1 2 3 4 5 6 7 NA
CASE MANAGEMENT
OVERALL RATING
1 2 3 4 5 6 7 NA
1. documents all client-related notes & reports clearly, concisely, and in a timely manner
2. attends to client assignment, appointments, follow-up and referrals in responsible and
timely manner
3. maintains confidentiality and security of client materials
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
OVERALL RATING
1 2 3 4 5 6 7 NA
1. demonstrates knowledge of APA ethical principles and applies these appropriately
2. recognizes and appropriately addresses ethical issues/dilemmas in clinical work and
professional relationships
3. considers multicultural issues as they may impact ethical issues/dilemmas
4. exhibits maturity and depth in discussing ethical and professional issues
5. is aware of the potential impact of one’s physical presentation (e.g. attire)
6. maintains appropriate professional boundaries in various clinical and professional
relationships
7. demonstrates a mature sense of professional responsibility to clients, colleagues, staff,
trainees, and the agency as a whole
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
DIVERSITY
OVERALL RATING
1 2 3 4 5 6 7 NA
1. demonstrates sensitivity to the impact of diversity issues in all its many forms on the
personal, interpersonal, and social experiences of our clients
2. demonstrates awareness of the impact of diversity issues on one’s own experiences,
values, assumptions and reactions
3. demonstrates sensitivity to the impact of individual and cultural differences on the
therapy relationship and process
4. demonstrates good judgment in regards to when/how to address issues of diversity
explicitly in therapy content and process
5. exhibits sensitivity and awareness of diversity issues as they may impact relationships
with colleagues, supervisors, trainees, etc.
1 2 3 4 5 6 7 NA
ETHICS & PROFESSIONAL BEHAVIOR
SUPERVISION PROCESS
& RELATIONSHIP W/ SUPERVISOR
OVERALL RATING
1
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NA
NA
NA
NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
regularly comes prepared for supervision
takes appropriate risks in showing/sharing one’s clinical work to supervisor
actively seeks and receives constructive feedback non-defensively
incorporates feedback productively into clinical and professional activities
processes issues within the supervisory relationship, including difficulties or conflicts,
openly with the supervisor
6. appropriately communicates one’s own experiences and needs in supervision
7. maintains appropriate boundaries
1
1
1
1
1
SELF-AWARENESS
1 2 3 4 5 6 7 NA
1.
2.
3.
4.
5.
OVERALL RATING
1. openly engages in self-exploration, as relevant to clinical & professional growth
2. demonstrates awareness of one’s own reactions and its impact on therapy and
supervision processes
3. recognizes and acknowledges one’s strengths, clinically & professionally
4. recognizes and acknowledges one’s limitations and areas for growth clinically &
professionally
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NA
NA
NA
NA
NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
PROFESSIONAL IDENTITY DEVELOPMENT
OVERALL RATING
1. developing a clinical/theoretical orientation that is consistent with one’s sense of self,
values, and interests
2. developing a clearer sense of career direction and professional identify that is
consistent with one’s sense of self, values, and interests
3. maintains openness to further exploration of one’s professional identity and a
commitment to life-long learning and growth
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
1 2 3 4 5 6 7 NA
SPECIFIC STRENGTHS:
SPECIFIC AREAS OF NEEDED GROWTH:
NEW/REVISED TRAINING GOALS:
__________________________________
Supervisee’s signature
Date
(8/08 SKK)
_____________________________________
Supervisor’s signature
Date