Name of Site Supervisor___________________________________________________
Name of Site_________________________________________________________________
Name of Student_______________________________ Term/Year _________________
Key: 0 = Insufficient opportunity to observe
1 = Needs much improvement
2 = Needs some improvement
3 = Meets expectations
4 = Superior
Characteristics
Circle one
1. Prompt
0 1 2 3 4
2. Dependable
0 1 2 3 4
3. Responsible
0 1 2 3 4
4. Shows initiative
0 1 2 3 4
5. Cooperative
0 1 2 3 4
6. Appropriate appearance
0 1 2 3 4
7. Rapport with staff members
0 1 2 3 4
8. Rapport with clients
0 1 2 3 4
9. Actively seeks new learning experiences
0 1 2 3 4
Supervision
1. Accepts constructive criticism and recommendations
0 1 2 3 4
2. Open and honest in supervisory sessions
0 1 2 3 4
3. Seeks help and direction
0 l 2 3 4
4. Prepared
0 l 2 3 4
5. Is specific In dealing with problem areas
0 1 2 3 4
6. In the space below, provide any general comments regarding your above
ratings and suggestions of areas of improvement:
Individual Counseling Circle One
1. Applies theoretical concepts to counseling situations. (In this
0 1 2 3 4
space, please comment on your own observations of trainee's
counseling ability and use of theory and techniques in counseling
situations.)
2. Please comment in this space on your observations of the trainee's
0 1 2 3 4
ability to establish and maintain the counseling relationship.
3. Please comment on your observation of the trainee's ability to
0 1 2 3 4
bring about change in clients.
Group Experience
Indicate here any group experience that the trainee undertook as well
0 1 2 3 4
as the specific type of group conducted (training, value clarification,
parent effectiveness training, etc.) and the outcome achieved.
Test Administration and Interpretation
Please indicate here the types of psychometrics the trainee administered
0 1 2 3 4
and your observations of the trainee's ability to interpret results
appropriately.
Consultation
1. Indicate here the trainee's ability to act as a consultant and to
act as a
0 1 2 3 4
source of referral to other persons or agencies.
2. Indicate here the trainee's ability to seek assistance through consultation
0 1 2 3 4
with other professionals.
Overall Evaluation
0 1 2 3 4
Additional Comments:
Supervisor's Signature ______________________________________________ Date ________
Intern's Signature __________________________________________________ Date ________
My signature indicates that I have read the above report and have discussed
the contents with my supervision. It does not indicate that I agree with
the report in part or in whole.
Northeastern
Illinois
University
5500 NORTH ST. LOUIS AVENUE
CHICAGO, ILLINOIS 60625-4699
Department of Counselor Education
This evaluation form should be completed by the practicum~internship student at the end of the practicum /internship experience. Discussion of the form with the site supervisor being evaluated is encouraged but not required.
Name of Site Supervisor _______________________________Name of Site________________________________
Name of Student _________________________________________ Term/Year
____________________________
DlRECTIONS: Circle
the number which best represents how
you, the student, perceive the supervision
received at your site.
Key: 0 = Insufficient opportunity to observe/experience
I = Needs much improvement
2 = Needs some improvement
3 = Meets expectations
4 = Superior
My site supervisor: Circle One
1. gives time and energy in observing, tape processing and case conferences.
0 1 2 3 4
2. accepts and respects me as a person.
0 1 2 3 4
3. recognizes and encourages further development of my strengths and
capabilities.
0 1 2 3 4
4. gives me useful feedback when I do something well.
0 1 2 3 4
5. provides me the freedom to develop flexible and effective counseling
styles.
0 1 2 3 4
6. encourages and listens to my ideas and suggestions for developing
my counseling skills.
0 1 2 3 4
7. provides suggestions for developing my counseling skills.
0 1 2 3 4
8. helps me to understand the implications and dynamics of the counseling
approaches I use.
0 1 2 3 4
9. encourages me to use new and different techniques when appropriate;
0 1 2 3 4
10. is spontaneous and flexible in the supervisory sessions.
0 1 2 3 4
11. helps me to define and achieve specific concrete goals for myself
during the practicum experience, 0 1 2 3
4
12. gives me useful feedback when I do something inappropriate.
0 1 2 3 4
13. allows me to discuss problems I encounter in my practicum setting.
0 1 2 3 4
14. focuses on both verbal and nonverbal behavior in me and in my clients.
0 1 2 3 4
15. helps me define and maintain ethical behavior in counseling and
case management.
0 1 2 3 4
16. encourages me to engage in professional behavior.
0 1 2 3 4
17. maintains confidentiality in material discussed in supervisory
sessions.
0 1 2 3 4
18. deals with both content and affect when supervising.
0 1 2 3 4
19. focuses on the implications, consequences, and contingencies of
specific behaviors in
counseling and supervision
0 1 2 3 4
20. helps me organize relevant case data in planning goals and strategies
with my client.
0 1 2 3 4
21. helps me to formulate a theoretically sound rationale of human
behavior.
0 1 2 3 4
22. offers resource information when I request or need it.
0 1 2 3 4
23. helps me develop increased skill in critiquing and gaining insight
from my counseling tapes.
0 1 2 3 4
24. allows and encourages me to evaluate myself.
0 1 2 3 4
25. explains his/her criteria for evaluation clearly
0 1 2 3 4
26. applies his/her criteria fairly in evaluating my counseling performance.
0 1 2 3 4
ADDITIONAL COMMENTS AND/OR SUGGESTIONS
Student's Signature _________________________________________Date ___________________________