WAUBONSEECOMMUNITY COLLEGE

HUMAN SERVICES TRAINING PROGRAM

AODA INTERNSHIP EVALUATION

This packet contains two evaluation forms. The first section is to be completed by the Field Site Supervisor. This evaluation contains ratings on the following areas:

  1. Transdisciplinary Foundations
  1. Understanding Addiction
  2. Treatment Knowledge
  3. Application to Practice
  4. Professional Readiness
  1. Core Clinical Skills
  1. Screening
  2. Intake
  3. Orientation
  4. Assessment
  5. Treatment Planning
  6. Counseling
  7. Case Management
  8. Crisis Intervention
/
  1. Client Education
  2. Referral
  3. Reports and Record Keeping
  4. Consultation with Other Professionals
  1. General Professional Development
  1. Capacity to work within agency structure
  2. Professional development
  3. Caseload management
  4. Practice skills
  5. Supervision

Not all areas will be able to be assessed by the Field Site Supervisor.Iif that is the case mark the “0”. The rating of “0” is not a negative rating for the intern.

The intern completes the second section

  1. Field Site Evaluation
  2. Field Site Supervision Evaluation

The Field Site Supervisor and the intern should complete their respective parts independently of each other. At a supervisory session, each should share their ratings with the other, discuss specific issues covered in the evaluation, and review the comments made. The Field Site Supervisor and the intern should then sign the evaluations. Each should keep a copy for their records. It is the responsibility of the intern to submit the original copy of the evaluation package to their instructor before the end of the semester. Students who do not submit the completed package will not receive a grade for the internship.

Any questions regarding the completion of this evaluation package should be directed to:

John Reese MS, CSADC

Instructor

WaubonseeCommunity College

(630) 466-2461

5/05

WaubonseeCommunity College

Human Services Counselor Training Program

Internship Evaluation Packet

I.SUPERVISOR’S EVALUATION OF INTERN

NAME OF AGENCY: ______DATE:______

STUDENT’S NAME:______SUPERVISOR’S NAME: ______

DATES OF INTERNSHIP: FROM ______TO ______

Your evaluation of the student contains threesections. The first section is transdisciplinary foundations, the second section is your rating of the intern’s core clinical skills, the third section consists of your rating of the interns general professional development. The rating key is as follows:

1 - Unsatisfactory2 - Needs improvement

3 - Appropriate for educational level4 - Above average

5 - Exceeds expectations0 - Unable to assess

Section 1. Transdisciplinary Foundations

The knowledge and attitudes that are prerequisite to the competent professional treatment of chemical dependency and other substance-relateddisorders.

Understanding Addiction

Competencies / 1 / 2 / 3 / 4 / 5 / 0
1. Understands a variety of models and theories of addiction and other problems related to substance use.
2. Recognizes the social, political, economic, and cultural context within which addiction and substance abuse exist, including risk and resiliencyfactors that characterize individuals and groups and their living environments.
3. Recognizes the behavioral, psychological, physical health, and social effects of psychoactive substances on the user and significant others.
4. Recognizes the potential for substance use disorders to mimic a variety of medical and psychological disorders and the potential for medicaland psychological disorders to co-exist with addiction and substance use

Page 2. Supervisor’s Evaluation

The rating key:

1 - Unsatisfactory2 - Needs improvement

3 - Appropriate for educational level4 - Above average

5 - Exceeds expectations0 - Unable to assess

Treatment Knowledge

Competencies / 1 / 2 / 3 / 4 / 5 / 0
1. Describe the philosophies, practices, policies, and outcomes of the most generally accepted and scientifically supported models of treatment, recovery, relapse prevention, and continuing care for addiction and other substance-related problems.
2. Recognize the importance of family, social networks, and community systems in the treatment and recovery process.
3. Understand the importance of research and outcome data and their application in clinical practice.
4. Understand the value of an interdisciplinary approach to addiction treatment.

Application to Practice

Competencies / 1 / 2 / 3 / 4 / 5 / 0
1. Understands the established diagnostic criteria for substance use disorders and describe treatment modalities and placement criteria within the continuum of care.
2. Demonstrates a variety of helping strategies for reducing the negative effects of substance use, abuse, and dependence.
3. Tailors helping strategies and treatment modalities to the client’s stage of dependence, change, or recovery.
4. Provides treatment services appropriate to the personal and cultural identity and language of the client.
5. Adapts practice to the range of treatment settings and modalities.
6. Is familiar with medical and pharmacological resources in the treatment of substance use disorders.
7. Understands the variety of insurance and health maintenance options available and the importance of helping clients access those benefits.
8. Recognizes that crisis may indicate an underlying substance use disorder and may be a window of opportunity for change.
9. Understands the need for and the use of methods for measuring treatment outcome.

Page 3. Supervisor’s Evaluation

The rating key:

1 - Unsatisfactory2 - Needs improvement

3 - Appropriate for educational level4 - Above average

5 - Exceeds expectations0 - Unable to assess

Professional Readiness

Competencies / 1 / 2 / 3 / 4 / 5 / 0
1. Understands diverse cultures and incorporate the relevant needs of culturally diverse groups, as well as people with disabilities, into clinical practice.
2. Understands the importance of self-awareness in one’s personal, professional, and cultural life
3. Understands the addiction professional’s obligations to adhere to ethical and behavioral standards of conduct in the helping relationship.
4. Adhere to Federal and State laws and agency regulations regarding treatment.
5. Understands the obligation of the addiction professional to participate in prevention as well as treatment.
6. Understands and applies setting-specific policies and procedures for handling crisis or dangerous situations, including safety measures for clients and staff.
7. Adhere to Federal and State laws and agency regulations regarding the confidentiality of clinical records/information.

Overall rating for this section

1 2 3 4 5

COMMENTS:

[USE BACK AS NEEDED]

Page 4. Supervisor’s Evaluation

Section 2. Core Functions of the Substance Abuse Counselor

The rating key:

1 - Unsatisfactory2 - Needs improvement

3 - Appropriate for educational level4 - Above average

5 - Exceeds expectations0 - Unable to assess

Screening:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
1. Evaluate psychological, social, and physiological signs and symptoms of alcohol and other drug use and abuse.
2. Determine the client’s appropriateness for admission or referral.
3.
Determine the client’s eligibility for admission or referral.
4. Identify any coexisting conditions (medical, psychiatric, physical, etc.) that indicate need for additional professional assessment and/or services.
5. Adheres to applicable laws, regulations and agency policies governing alcohol and other drug abuse services.

Intake:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
6. Complete required documents for admission to the program
7. Complete required documents for program eligibility and appropriateness.
  1. Obtain appropriately signed consents when soliciting from or providing information to outside sources to protect client confidentiality and rights.

Orientation:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
9. Provide an overview to the client by describing program goals and objectives for client care.
10. Provide an overview to the client by describing program rules, and client obligations and rights.
11.
Provide an overview to the client of program operations.

Page 5. Supervisor’s Evaluation

The rating key:

1 - Unsatisfactory2 - Needs improvement

3 - Appropriate for educational level4 - Above average

5 - Exceeds expectations0 - Unable to assess

Assessment:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
  1. Gather relevant history from client including, but not limited to alcohol and other drug abuse using appropriate interview techniques.

  1. Identify methods and procedures for obtaining corroborative information from significant secondary sources regarding client’s alcohol and other drug abuse and psycho-social history

  1. Identify appropriate assessment tools.

  1. Explain to the client the rationale for the use of assessment techniques in order to facilitate understanding.

  1. Develop a diagnostic evaluation of the client’s substance abuse and any coexisting conditions based on the results of all assessments in order to provide an integrated approach to treatment planning based on the client’s strengths, weaknesses, and identified problems and needs.

Treatment Planning:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
17. Explain assessment results to client in an understandable manner.
18. Identify and rank problems based on individual client needs in the written treatment plan.
19. Formulate agreed upon immediate and long-term goals using behavioral terms in the written treatment plan.
20. Identify the treatment methods and resources to be utilized as appropriate for the individual client.

Page 6. Supervisor’s Ealuation

Core Functions of the Substance Abuse Counselor

The rating key:

1 - Unsatisfactory2 - Needs improvement

3 - Appropriate for educational level4 - Above average

5 - Exceeds expectations0 - Unable to assess

Counseling:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
21. Select the counseling theory that applies.
22. Apply technique(s) to assist the client, group, and/or family in exploring problems and ramifications.
  1. Apply technique(s) to assist the client, group, and/or family in examining the client’s behavior, attitudes, and/or feelings if appropriate in the treatment setting.

24. Individualize counseling in accordance with cultural, gender, and lifestyle differences.
25. Interact with the client in an appropriate therapeutic manner.
26. Elicit solutions and decisions from the client
  1. Implement the treatment plan.

Case Management:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
28. Coordinate services for client care.
29.
  1. Explain the rationale of case management activities to the client.

Crisis Intervention:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
30. Recognize the elements of the clientcrisis.
31. Implement an immediate course of action appropriate to the crisis.
32.
  1. Enhance overall treatment by utilizing crisis events.

Page 7. Supervisor’s Evaluation

Core Functions of the Substance Abuse Counselor

The rating key:

1 - Unsatisfactory2 - Needs improvement

3 - Appropriate for educational level4 - Above average

5 - Exceeds expectations0 - Unable to assess

Client Education:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
33. Present relevant alcohol and other drug use/abuse information to the client through formal and/or informal processes.
34. Present information about available alcohol and other drug services and resources.

Referral:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
35. Identify need(s) and/or problem(s) that the agency and/or counselor cannot meet.
36. Explain the rationale for the referral to the client.
37. Match client needs and/or problems to appropriate resources.
38. Adhere to applicable laws, regulations and agency policies governing procedures related to the protection of the client’s confidentiality.
  1. Assist the client in utilizing the support systems and community resourcesavailable.

Report and Record Keeping:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
40. Prepare reports and relevant records integrating available information to facilitate the continuum of care.
41.Chart pertinent ongoinginformation pertaining to the client.
42. Utilize relevant information from written documents for client care.

Page 8. Supervisor’s Evaluation

Core Functions of the Substance Abuse Counselor

The rating key:

1 - Unsatisfactory2 - Needs improvement

3 - Appropriate for educational level4 - Above average

5 - Exceeds expectations0 - Unable to assess

Consultation With Other Professionals in Regard to Client Treatment/Services:

Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
43. Recognize issues that are beyond the counselor’s base of knowledge and/or skill.
44. Consult with appropriate resources to ensure the provision of effective treatment services
45. Adhere to applicable laws, regulations and agency policies governing the disclosure of client- identifying data.
46.Explain the rationale for the consultation to the client, if appropriate

Overall rating for this section

1 2 3 4 5

COMMENTS:

[USE BACK AS NEEDED]

Page 9. Supervisor’s Eevaluation

Section 3. General Professional Development

The rating key is:

1 - Unsatisfactory2 - Needs improvement

3 - Satisfactory/meets requirements4 - Above average

5 - Exceeds expectations0 - Unable to assess

Capacity to work within agency structure and functions
Competencies / 1 / 2 / 3 / 4 / 5 / 0
a. relating and communications with staff
b. presents self in professional fashion
c. understands goal/mission of agency
d. willingness to assist staff as needed
e. contributes to overall program
g. positive approach to duties
Professional development
Competencies / 1 / 2 / 3 / 4 / 5 / 0
a. awareness of self
b. responsible for self (sets limits/boundaries)
c. initiative
d. availability to clients/staff
e. leadership abilities
f. punctuality/attendance
g. stress management (self)
h. ability to handle stress/crisis situations
i. dependability
Caseload Management
Competencies / 1 / 2 / 3 / 4 / 5 / 0
a. documentation of services provided
b. documentation done on time
c. time utilization skills
d. keeps treatment focused
e. phone calls made on timely basis
f. promptness to program activity
g. quality of charting
h. neatness of charting
i. accuracy of charting
j. timeliness of charting

Page 10. Supervisor’s Evaluation

The rating key is:

1 - Unsatisfactory2 - Needs improvement

3 - Satisfactory/meets requirements4 - Above average

5 - Exceeds expectations0 - Unable to assess

Practice skills
a. Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
b. integrate theory with practice
c. observation skills
d. assessment skills
e. listening skills
f. interviewing skills
g. case planning skills
h. flexibility with unique consumer needs
i. ability to chose appropriate client tasks
Supervision
a. Competencies—intern’s ability to / 1 / 2 / 3 / 4 / 5 / 0
b. makes use of learning events
c. acceptance of role as learner
d. takes responsibility for learning
e. accepts constructive criticism
f. values supervisions
g. seeks out supervision
h. appropriate use of supervision
i. brings appropriate issues to supervision
j. openness for growth experiences

Overall rating for this section

1 2 3 4 5

COMMENTS:

[USE BACK AS NEEDED]

Page 11. Supervisor’s Evaluation

SUPERVISOR’S OVERALL RATING FOR THIS STUDENT INTERN

1. UNSATIFACTORY/FAILED TO FULFILL MIMINAL REQUIREMENTS

2. NEEDS IMPROVEMENT/FULFILLED MINIMAL REQUIREMENTS

3. SATISFACTORY REQUIRMENTS FULLILLED

4. ABOVE AVERAGE/ALL REQUIRMENTS CONSISTENTLY WELL DONE

5. EXCEEDS EXPECTATIONS/EXCEEDED REQUIREMENTS

COMMENTS:

SIGNATURES:

Intern: ______Date: ______

Supervisor: ______Date: ______

Instructor: ______Date: ______

WaubonseeCommunity College

Human Services Counselor Training Program

Internship Evaluation Packet

II.FIELD SITE EVALUATION

(student evaluation OF internship experience)

NAME OF AGENCY: ______DATE:______

SUPERVISORS NAME: ______STUDENT’S NAME: ______

DATES OF INTERNSHIP: FROM ______TO ______

This section of the evaluation package is to be completed by the intern. It is to be based upon their evaluation of the agency/facility where the internship took place. The evaluation should be reviewed and discussed with the site supervisor and a copy given to that supervisor.

Intern’s assessment of the programs of services offered by the agency.

[ ] excellent [ ] good [ ] fair [ ] poor

Reason for the above response: (use back as needed)

  1. Was the program prepared for your internship?[ ] Yes [ ] No
  2. Do you feel you were welcomed and accepted?[ ] Yes [ ] No
  3. Were you exposed to a variety of activities?[ ] Yes [ ] No
  4. Do you feel your efforts were valued?[ ] Yes [ ] No
  5. Do you feel your opinions/skills/knowledge

were valued?[ ] Yes [ ] No

Site Evaluation page 2

Comments regarding 1-5:

What portion of this internship was the MOST beneficial to you?

What portion of this internship was LEAST beneficial to you?

Site Evaluation, page 3

What changes would you recommend to be made for future internships at this agency?

Would you recommend this agency/facility to another student at WaubonseeCommunity College?

[ ] No

[ ] Yes-with student specific reservations (type student you would or would not recommend)

[ ] Yes, no reservations

SIGNATURES:

Intern: ______Date: ______

Supervisor: ______Date: ______

Instructor: ______Date: ______

WaubonseeCommunity College

Human Services Counselor Training Program

Internship Evaluation Packet

III.FIELD SITE SUPERVISION EVALUATION

NAME OF AGENCY: ______DATE:______

STUDENT’S NAME:______SUPERVISOR’S NAME: ______

DATES OF INTERNSHIP: FROM ______TO ______

Supervisor Evaluation:

  1. Awareness of your needs as an intern?[ ] Yes [ ] No
  2. Available for formal supervision?[ ] Yes [ ] No
  3. Available for informal supervision?[ ] Yes [ ] No
  4. Internship responsibilities made clear?[ ] Yes [ ] No
  5. Agency policy and procedures made clear?[ ] Yes [ ] No
  6. Proposed new and creative ideas to aid learning?[ ] Yes [ ] No
  7. Willingness to extend self to assist learning?[ ] Yes [ ] No
  8. Kept intern informed of program activities

and changes?[ ] Yes [ ] No

  1. Clearly communicated expectations?[ ] Yes [ ] No
  2. Able to work through conflicts with intern?[ ] Yes [ ] No
  3. Ability to be flexible?[ ] Yes [ ] No
  4. Supportive to intern’s growth and learning?[ ] Yes [ ] No
  5. Able to confront intern as needed?[ ] Yes [ ] No
  6. Followed through on commitments to intern?[ ] Yes [ ] No
  7. Sufficient direct observations of intern’s

performance in program activities?[ ] Yes [ ] No

  1. Would you recommend this supervisor to

future interns? [ ] Yes [ ] No

SIGNATURES:

Intern: ______Date: ______

Supervisor: ______Date: ______

Instructor: ______Date: ______