"Intern Performance Evaluation Form"

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Form J-Internship (page 1 of 3)
Intern Performance Evaluation Form
Student: ________________________________________________ Date_______________________
Supervisor: _____________________________________________ Site _______________________
Term: ____Fall ____Winter ____Spring ____Summer
Intern’s final term at site? __Yes __No
Term in Practicum/Internship Sequence:
First
Second
Third
Fourth or more
This form should be completed by the site supervisor at the end of each term. Four domains of
Intern competence are listed below along with specific items in each domain. Circle the number
to the right of each item that best describes your perceptions of the intern’s skills compared to all
other people you have trained at the same level of professional development. If the current
evaluation is for the intern’s final term at the site, it should be treated as a summative evaluation.
(The term “client” as used herein refers to any person receiving services including students,
parents, teachers or patients.) IO = Inadequate Opportunity to Observe
NR = Not Relevant to the Setting
Clearly
Clearly
Clearly
Counseling Skill
Deficient
Adequate
Excellent
Competency
1
2
3
4
5
IO
NR
Explains the nature and objectives of counseling
1
2
3
4
5
IO
NR
when appropriate.
Conducts a systematic and complete intake
1
2
3
4
5
IO
NR
interview
Establishes a working relationship with clients.
1
2
3
4
5
IO
NR
Gains client confidence.
1
2
3
4
5
IO
NR
Conveys warmth to the client
1
2
3
4
5
IO
NR
Conveys competence to the client
1
2
3
4
5
IO
NR
Facilitates the client expression of thought and
1
2
3
4
5
IO
NR
feeling
Specifies the client problems in concrete terms
1
2
3
4
5
IO
NR
Uses a variety of counselor responses.
1
2
3
4
5
IO
NR
Responds to client affect.
1
2
3
4
5
IO
NR
Helps client explore personal alternatives.
1
2
3
4
5
IO
NR
Establishes relevant counseling goals with client.
1
2
3
4
5
IO
NR
Balances between implementing planned strategies
1
2
3
4
5
IO
NR
and remaining spontaneous in the counseling
session.
Implements an intervention strategy consistent with
1
2
3
4
5
IO
NR
client information and goals.
Form J-Internship (page 1 of 3)
Intern Performance Evaluation Form
Student: ________________________________________________ Date_______________________
Supervisor: _____________________________________________ Site _______________________
Term: ____Fall ____Winter ____Spring ____Summer
Intern’s final term at site? __Yes __No
Term in Practicum/Internship Sequence:
First
Second
Third
Fourth or more
This form should be completed by the site supervisor at the end of each term. Four domains of
Intern competence are listed below along with specific items in each domain. Circle the number
to the right of each item that best describes your perceptions of the intern’s skills compared to all
other people you have trained at the same level of professional development. If the current
evaluation is for the intern’s final term at the site, it should be treated as a summative evaluation.
(The term “client” as used herein refers to any person receiving services including students,
parents, teachers or patients.) IO = Inadequate Opportunity to Observe
NR = Not Relevant to the Setting
Clearly
Clearly
Clearly
Counseling Skill
Deficient
Adequate
Excellent
Competency
1
2
3
4
5
IO
NR
Explains the nature and objectives of counseling
1
2
3
4
5
IO
NR
when appropriate.
Conducts a systematic and complete intake
1
2
3
4
5
IO
NR
interview
Establishes a working relationship with clients.
1
2
3
4
5
IO
NR
Gains client confidence.
1
2
3
4
5
IO
NR
Conveys warmth to the client
1
2
3
4
5
IO
NR
Conveys competence to the client
1
2
3
4
5
IO
NR
Facilitates the client expression of thought and
1
2
3
4
5
IO
NR
feeling
Specifies the client problems in concrete terms
1
2
3
4
5
IO
NR
Uses a variety of counselor responses.
1
2
3
4
5
IO
NR
Responds to client affect.
1
2
3
4
5
IO
NR
Helps client explore personal alternatives.
1
2
3
4
5
IO
NR
Establishes relevant counseling goals with client.
1
2
3
4
5
IO
NR
Balances between implementing planned strategies
1
2
3
4
5
IO
NR
and remaining spontaneous in the counseling
session.
Implements an intervention strategy consistent with
1
2
3
4
5
IO
NR
client information and goals.
Evaluates client progress with respect to goals.
1
2
3
4
5
IO
NR
Addresses interpersonal dynamics between self and
1
2
3
4
5
IO
NR
client (comments on the process)
Monitors own reactions to clients
1
2
3
4
5
IO
NR
Facilitates the client’s resolution of concerns.
1
2
3
4
5
IO
NR
Appropriately refers and terminates clients.
1
2
3
4
5
IO
NR
Understands diverse cultural, ethnic, sexual, and
1
2
3
4
5
IO
NR
social backgrounds and values
Clearly
Clearly
Clearly
Conceptualization Skills
Deficient
Adequate
Excellent
Conceptualizes a case accurately.
1
2
3
4
5
IO
NR
Develops appropriate goals as a result of
1
2
3
4
5
IO
NR
conceptualization.
Understands interplay between strategies & goals.
1
2
3
4
5
IO
NR
Identifies key themes relevant to the client.
1
2
3
4
5
IO
NR
Identifies key factors maintaining client problems
1
2
3
4
5
IO
NR
Clearly
Clearly
Clearly
Supervision Competency
Deficient
Adequate
Excellent
Meets with supervisor as scheduled.
1
2
3
4
5
IO
NR
Forms working relationship with supervisor.
1
2
3
4
5
IO
NR
Handles feedback well.
1
2
3
4
5
IO
NR
Uses supervision constructively.
1
2
3
4
5
IO
NR
Open to growth and learning.
1
2
3
4
5
IO
NR
Clearly
Clearly
Clearly
Professional Skill Competency
Deficient
Adequate
Excellent
Willingly assumes responsibility
1
2
3
4
5
IO
NR
Establishes and maintains facilitative working
1
2
3
4
5
IO
NR
relationship with staff.
Shares skills and competencies with peers and
1
2
3
4
5
IO
NR
supervisors.
Keeps adequate and timely client records and
1
2
3
4
5
IO
NR
documentation.
Behaves professionally (e.g., demeanor, dress,
1
2
3
4
5
IO
NR
language, commitments, etc.).
Organizes and recognizes implications of case
1
2
3
4
5
IO
NR
material.
Accurately evaluates own counseling session
1
2
3
4
5
IO
NR
performance.
Behaves ethically and responsibly with clients,
1
2
3
4
5
IO
NR
colleagues, and adjunct agencies.
Manages time well.
1
2
3
4
5
IO
NR
Follows through on professional commitments.
1
2
3
4
5
IO
NR
Comments:_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Suggested grade: ______ Pass
______ No Pass
In comparison to other counselors at this stage in their training, how would you evaluate this person’s
performance?
1
2
3
4
5
6
7
8
9
Clearly
Like
Clearly
Deficient
Others
Excellent
Total number of hours at internship site: _____________
______________________________________
_____________________
Signature of Site Supervisor
Date
: ______________________
Site Phone Number
If this is the last supervision assessment: I will be willing to sign off on the NCC Supervisors Form
Yes ___
No ___
My signature indicates I have read and discussed the material above with my internship supervisor.
It does not indicate my total or partial agreement with the evaluation.
______________________________________
____________________
Signature of Intern
Date
Intern Phone Number: ____________________
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