School and Clinical Child Psychology Program

CLINICAL PROGRESS FORM

For Course Use

This form has two functions:

The first function of this form is to help students keep track of the total number of hours of clinical experience that they have obtained. This form provides a structure that helps them to do this. It should be completed for all SCCP courses that involve direct client contact (e.g., 1216, 5284 and sometimes for 3222 and 3240). These forms should be handed out at the beginning of the practicum course. Students should make a copy and give the original to the Director of Clinical Training (DCT). The DCT will file these in the students’ files.

Please be advised that this form pertains only to program-sanctioned training or work experiences. If you have obtained additional, relevant work experience, these hours can be documented elsewhere (on another form).

A second function of this form is to formally monitor the early clinical performance of students in course 1216 to ensure that each student is ready for a practicum placement.

Please fill out the following information:

Name of Student / Student Number
Name of Supervisor
Name of Course
Time Period / From: / To:

GENERAL INSTRUCTIONS:

  • Sections 1& 2 are to be filled out by the student & reviewed by the supervisor. Section 3 is to be filled out by the supervisor.

SECTION 1

1.INTERVENTION AND ASSESSMENT EXPERIENCE (DIRECT SERVICES) –

How much experience do you have with different types of psychological interventions and assessment?

For this question (Question 1), please summarize professional activities that you have provided in the presence of a client / patient. Professional activities that are not provided in the presence of a client should be summarized in Question 4 (Support Activities). Activities that pertain to a client / patient but did not take place in the presence of the client / patient (e.g., gathering information about a client / patient), should be recorded in Question 4 (Support Activities).

When quantifying your practicum experience, you must use your best judgment of the time spent in different activities and the number of clients / patients seen. If an exact number is not available, please use a best estimate and consult with your training director as needed.

  • A practicum hour should be a full clock hour, not a partial hour. However, a 45-50 minute client/patient meeting can be counted as a full practicum hour.
  • Unless otherwise indicated, please note that the categories are intended to be mutually exclusive; that is, a practicum hour counted in one section should not be counted in another section as well. Some experiences might seem to fall under more than one section; however, you must decide which section best captures the experience and record your time in this section. (For example, a Relaxation group might be classified as a ‘group,’ or a ‘Medical / Health-Related Intervention,’ but not both.)
  • When documenting an hour spent with a group of clients / patients (e.g., a couple, family, group), this should be recorded as one hour in total (i.e., do not count an hour for each separate person in the group).
  • In the “# of different…” category, please count a group (e.g., a couple, family, group) as one (1) unit. For example, if a student met with a group of 10 clients / patients for an hour session over a period of 8 weeks, this would count as 8 hours and one (1) group. A group with open membership is also counted as one (1) unit.

Before completing this table, please review the guidelines above.

List (if any) the type of therapy or counseling you provided (e.g., Individual Therapy, Group Counseling, Family Therapy) / Total hours
face-to-face / # of different
INDIVIDUALS
In this space, list the ages of the client(s):
  1. Psychological Assessment Experience: This is the estimated total hours spent administering tests to clients / patients, face-to-face. Also include in this section the total hours spent providing feedback to clients / patients. However, do not include time spent scoring tests or report writing; the latter activities can be documented in the Question 4 (Support Activities). Information about the number of tests scored will be recorded elsewhere (in Section 2).

PSYCHOLOGICAL ASSESSMENT EXPERIENCE
Total hours
face-to-face
1) Psychodiagnostic test administration (include symptom assessment, projectives, personality, objective measures, achievement, intelligence and career assessment), and providing feedback to clients / patients.
2) Neuropsychological Assessment (include intellectual assessment in this category only when it was administered in the context of neuropsychological assessment involving evaluation of multiple cognitive, sensory, and motor functions).
3) Other (please specify):

2.SUPERVISION RECEIVED

Please summarize the amount of time you have spent receiving supervision from the different health care professionals listed in the table below. Note that ‘supervision’ is defined as the overseeing, by a health care professional, of psychological services rendered by the student. Supervision involves and evaluative component and the discussion of specific cases (e.g., supervisor’s feedback on an assessment plan or formulation presentation). Didactic portions of training should be documented in Question 4 (Support Activities); e.g., lectures would not be counted in this category.

  • Individual and group supervision are listed separately in the table. Individual supervision is one-on-one, face-to-face supervision.
  • Group supervision can include feedback received from the supervisor in class, and discussion of cases in class with the supervisor present

.

Before completing this table, please review the above guidelines.

Supervision provided by Licensed Psychologists / Allied Mental Health Professionals / Supervision provided by Advanced Grad Students Supervised by Licensed Psychologists (e.g., TA) / Total Supervision Hours
a. Individual Supervision Received
b. Group Supervision Received

3.INFORMATION ABOUT YOUR PRACTICUM EXPERIENCES

a. Treatment Settings

All your hours were likely obtained through the Department Clinic (OISE Psychology Clinic). If some of your hours were obtained in another setting, please explain your situation:

b. What kind of groups (if any) did you lead / co-lead?

Describe the type of group, the duration of the group, and the average number of clients present at each session.

c. Have you ever audiotaped, videotaped, or made digital recording of clients / patients and reviewed these with

your clinical supervisor?

 Yes No

d. In the table below, record the number of clients / patients you have worked with (therapy, counseling, or assessment) who are members of the diverse populations listed in the table below. In the ‘Assessment’ column, please include clients / patients for whom you performed assessments or intake interviews.

For this question, you can indicate a client / patient more than once if he / she fits in more than one row or

column. In terms of groups (e.g., couples, families, or groups), you can count each individual as a separate unit.

RACE / ETHNICITY /
Number of Different Clients / Patients Seen
Intervention / Assessment
African-American / Black / African Origin
Asian-American / Asian Origin / Pacific Islander
Latino-a / Hispanic
American Indian / Alaska Native / Aboriginal Canadian
European Origin / White
Bi-racial / Multi-racial
Other (please specify)[1]:
SEXUAL ORIENTATION /
Number of Different Clients / Patients Seen
Intervention / Assessment
Heterosexual
Gay
Lesbian
Bisexual
Other (please specify):
DISABILITIES /
Number of Different Clients / Patients Seen
Intervention / Assessment
Physical / Orthopedic Disability
Blind / Visually Impaired
Deaf / Hard of Hearing
Learning / Cognitive Disability
Developmental Disability (Including Autism)
Serious Mental Illness (e.g., primary psychotic disorders, major mood disorders that significantly interfere with adaptive functioning)
Other (please specify):
GENDER /
Number of Different Clients / Patients Seen
Intervention / Assessment
Male
Female
Transgender

4.SUPPORT ACTIVITIES

In this section, record the hours spent in activities that supported the intervention / assessment experiences.

In Question 4, please summarize professional activities that pertain to clients / patients but did not take place in the presence of clients / patients. Support activities include: gathering information about a client / patient outside of a session, providing distance interventions (e.g., by telephone or webcam), learning about tests, scoring tests, report writing, observing other professionals testing, reviewing video tapes of assessment sessions, and consulting with teachers / other professionals (e.g., class hours spent listening to classmates’ assessment plans). Didactic portions of training should also be documented here (e.g., presentations, lectures and/or ‘Grand Rounds’).

TOTAL HOURS SPENT IN SUPPORT ACTIVITIES:

Below, please indicate which activities comprised the support hours recorded in the above box:

SECTION 2

  1. TEST ADMINISTRATION

In the two tables that follow, please record which instruments you administered and scored in your practicum / internship. Separate tables are provided for instruments used with adults and children, respectively. Do not count practice administrations in the table.

  • In the first column of the table, indicate which tests you administered and scored. A sample list of tests is provided below, but please feel free to include tests that are not mentioned in this list.
  • In the second column, indicate the number of tests that you administered and scored. In the third column, indicate how many of those that you administered and scored in column one were subsequently interpreted in a report that you wrote.

SOME PSYCHOLOGICAL INSTRUMENTS FOR ADULTS / CHILDREN
Autism Spectrum Rating Scale / Myers-Briggs Type Indicator / Structured Diagnostic Interviews (e.g., K-
Bayley Scales of Infant Development
(Specify version) / Multilingual Aphasia Exam
MMPI-2 , MMPI-A / Strong Interest Inventory
TAT
BASC-2 / Parent Report Measures (e.g., CBCL) / Trail Making Test A & B
BRIEF-2 / Personality Assessment Inventory II / WIAT-III
Bender Gestalt / Projective Sentences / Sentence Completions / WRAML2
Benton Visual Retention Test / Peabody Picture Vocabulary Test / WISC-V
Boston Naming Test
California Verbal Learning Test
Conners 3rd Edition / Projective Drawings (includes Draw-a-Person Test and Kinetic Family Drawing) / Woodcock Johnson-III (Ach, Cog)
WPPSI-IV
Dementia Rating Scale-II / Rorschach (Specify scoring system) / WRAT (Specify version)
D-KEFS / Rey-Osterrieth Complex Figure / WAIS-IV
Human Figure Drawing / Roberts 2 / Wechsler Memory Scale-IV
Kinetic Family Drawing
Millon Adolescent Personality Inv. (MAPI) / Self-report measures of symptoms / disorders (e.g., Beck Depression Inventory II) / Wisconsin Card Sorting Test
Millon ClinicalMulti-Axial Inv. III (MCMI) / SCID-II
1. NAME OF TEST / # ADMINISTERED AND SCORED / # OF REPORTS WRITTEN
NAME OF TEST (Continued) / # ADMINISTERED AND SCORED / # OF REPORTS WRITTEN
  1. INTEGRATED REPORT WRITING –

How many supervised, integrated, psychological reports have you written for adults / children?

A report is considered ‘integrated’ if it satisfies the following criteria:

  • Includes a history,
  • Includes an interview,
  • Includes at least 2 tests from one or more of the following categories:
  • Personality assessments (objective, self-report, and/or projective)
  • Intellectual assessment
  • Cognitive assessment
  • Neuropsychological assessment
  • The final report integrates the abovementioned sections to provide a comprehensive, overall picture of the client / patient.

3. INTEGRATED REPORT WRITING / # INTEGRATED REPORTS
a. Adults
b. Children / Adolescents
In this space, list the ages of the client(s):
  1. TOTAL SUMMARY OF HOURS (please add to page 10)

SECTION 3

Student Performance Evaluation

To be filled out by the supervisor

The supervisor may choose one of two reference groups against which to compare the student’s performance:

The supervisor may wish to compare the students performance with that of fully qualified clinicians. Using this ranking, it is assumed that fully qualified clinicians will generally be in Performance Levels 4 and 3

The supervisor may wish to compare the student’s performance with that of other students at the same level

1. PROFESSIONAL BEHAVIOUR/INTERPERSONAL RELATIONSHIPS

Displays good work habits (e.g., plans work thoroughly, manages time effectively, makes efficient use of supervision time, is punctual) / IB / 1 / 2 / 3 / 4 / 5
Able to work independently, but consults as appropriate / IB / 1 / 2 / 3 / 4 / 5
Takes charge of situations and gets things done / IB / 1 / 2 / 3 / 4 / 5
Meets deadlines promptly / IB / 1 / 2 / 3 / 4 / 5
Perceives problem situations and deals with them effectively / IB / 1 / 2 / 3 / 4 / 5
Gets along and works well with others / IB / 1 / 2 / 3 / 4 / 5
Ability to work collaboratively with school and/or mental health professionals / IB / 1 / 2 / 3 / 4 / 5
Has an appropriately professional demeanour / IB / 1 / 2 / 3 / 4 / 5
Is aware of personal issues as they impact on clinical work / IB / 1 / 2 / 3 / 4 / 5
Responds appropriately to constructive criticism and supervision / IB / 1 / 2 / 3 / 4 / 5
Oral communications / IB / 1 / 2 / 3 / 4 / 5
Written communications / IB / 1 / 2 / 3 / 4 / 5

Comments on professional behaviour / interpersonal relationships:

2. ASSESSMENT AND EVALUATION SKILLS

Ability to establish rapport with patients/clients / IB / 1 / 2 / 3 / 4 / 5
Sensitivity to multicultural issues and the range of diversity (e.g. gender, socioeconomic) / IB / 1 / 2 / 3 / 4 / 5
Insight into client difficulties / IB / 1 / 2 / 3 / 4 / 5
Interviewing skills (e.g., clinical, intake) / IB / 1 / 2 / 3 / 4 / 5
Observational skills / IB / 1 / 2 / 3 / 4 / 5
Ability to formulate appropriate questions to be addressed by assessment / IB / 1 / 2 / 3 / 4 / 5
Selects appropriate tests for assessment / IB / 1 / 2 / 3 / 4 / 5
Breadth & knowledge regarding assessment materials / IB / 1 / 2 / 3 / 4 / 5
Accuracy and skill in administering and scoring tests / IB / 1 / 2 / 3 / 4 / 5
Ability to interpret & integrate assessment findings / IB / 1 / 2 / 3 / 4 / 5
Knowledge and application of diagnosis / IB / 1 / 2 / 3 / 4 / 5
Ability to relate assessment findings to recommendations / IB / 1 / 2 / 3 / 4 / 5
Quality of written reports / IB / 1 / 2 / 3 / 4 / 5
Effectively communicates results of assessment to clients and/or relevant others / IB / 1 / 2 / 3 / 4 / 5
Client file management (e.g., produces appropriate notes and records for client files) / IB / 1 / 2 / 3 / 4 / 5

Comments on assessment & evaluation skills:

3. INTERVENTION AND CONSULTATION

Ability to establish rapport with patients/clients / IB / 1 / 2 / 3 / 4 / 5
Sensitivity to multicultural issues and the range of diversity (e.g. gender, socioeconomic) / IB / 1 / 2 / 3 / 4 / 5
Insight into client difficulties / IB / 1 / 2 / 3 / 4 / 5
Interviewing skills (e.g., clinical, intake) / IB / 1 / 2 / 3 / 4 / 5
Observational skills / IB / 1 / 2 / 3 / 4 / 5
Knowledge of psychoeducational intervention techniques / IB / 1 / 2 / 3 / 4 / 5
Ability to apply psychoeducational intervention techniques / IB / 1 / 2 / 3 / 4 / 5
Knowledge of psychotherapeutic intervention techniques / IB / 1 / 2 / 3 / 4 / 5
Ability to apply psychotherapeutic intervention techniques / IB / 1 / 2 / 3 / 4 / 5
Keeps appropriate records of therapy/intervention progress / IB / 1 / 2 / 3 / 4 / 5
Evaluates ongoing progress during therapy/intervention / IB / 1 / 2 / 3 / 4 / 5
Client file management (e.g., produces appropriate notes and records for client files) / IB / 1 / 2 / 3 / 4 / 5

Comments on intervention & consultation:

4. ETHICS

Familiarity with ethical standards for psychologists, understands their implications, and acts accordingly / IB / 1 / 2 / 3 / 4 / 5
Demonstrates responsibility to clients, society, the profession and colleagues / IB / 1 / 2 / 3 / 4 / 5
Demonstrates knowledge of jurisprudence and local regulations / IB / 1 / 2 / 3 / 4 / 5
Awareness of and ability to deal appropriately with professional biases and beliefs including such issues as gender, race, cultural bias, classism and homophobia / IB / 1 / 2 / 3 / 4 / 5
Demonstrates knowledge of factors that may influence the professional relationship (e.g., boundary issues) / IB / 1 / 2 / 3 / 4 / 5
Is aware of personal limitations / IB / 1 / 2 / 3 / 4 / 5

Comments regarding ethics:

Additional comments or concerns regarding this student’s clinical progress in the above course:

TOTAL SUMMARY OF HOURS

a. Total Intervention Hours
a. Total Assessment Hours
a. Total Intervention and Assessment Hours (Question 1)
b. Total Supervision Hours
(Question 2)
c. Total Hours Spent in Support Activities (Question 5)
TOTAL HOURS OF CLINICAL EXPERIENCE
(Question 1 + 2 + 5)

SUPERVISORS MUST SIGN BELOW, WITH THE EXCEPTION OF 1216 SUPERVISORS, WHO MUST COMPLETE & SIGN THE FOLLOWING PAGE.

Signature of Supervisor Date

SECTION 4

FOR 1216 ONLY

The Supervisor of 1216 must complete the following

SUMMARY OF STUDENT CLINICAL PERFORMANCE FORM

PSYCHOLOGICAL ASSESSMENT

Course: 1216 /

Section #

/

Course Date (year/term)

Overall, in my opinion: This student’s performance is satisfactory. He/she is ready for a practicum placement.

Although I have one/some minor concern(s) in one/some area(s) of clinical practice, I basically feel that this student is ready for a practicum placement

I have one or more major concerns regarding this student’s clinical practice. I am not sure that this student is ready for a practicum placement.

I have pronounced concerns and do not feel that this student is ready for a practicum placement.

Comments:

Signature of Supervisor Date

STUDENT MUST COMPLETE: I acknowledge that I have reviewed this form together with my course instructor:

Signature of Student Date

NOTE: The student should make a photocopy of this form and submit the original copy to the SCCP Director of Clinical Training.

Updated: August2016

1

[1] Consider mentioning work with clients who are learning English (ESL), or children who are enrolled in French Immersion.