Doctor of Behavioral Health Program
Student Intern Mid-Semester Review
Site Contact Report
In preparation for the student one-on-one review meeting, contact the internship site to discuss the student’s progress and plans for completing the semester rotation. Please reference items from each of the reporting forms that the contact is using to monitor the student intern’s activities:
· Internship Training Plan – progress toward reaching stated goals and objectives
· Internship Evaluation – current ratings and those targeted for improvements by the end of the semester
· End of Semester Activity Record - reported hours to-date
The preceptor is the preferable contact since that person is intended to work most closely with the student intern. Email completed copies of this form to the Internship Coordinator and to the student.
Date of Contact ___/___/___ Semester ___ Fall ___ Spring ___ Summer Year ______
Student Name ______Consultant Name ______
Internship Site ______
Contact was made with (begin by attempting to contact the Preceptor):
o Preceptor - Name ______Phone (____) ______
o Site Liaison - Name ______Phone (____) ______
If the preceptor was unavailable for a consultation, describe the reason given:
Site contact’s general comments about student performance:
Site contact’s comments related to each student intern performance monitoring form:
· Internship Training Plan – Describe goals and objectives that have been reached and those that are in progress.
· Internship Evaluation – Describe select current ratings and those targeted for improvements by the end of the semester.
· End of Semester Activity Record – Ask the contact for the student intern’s current hours to-date to verify monitoring.
Site contact’s overall rating of student intern’s performance:
___ 1 – Below expectations
___ 2 – Meeting expectations
___ 3 – Exceeding expectations
Explanation of rating and, if 1 or 2, general recommendations for improving student performance this semester:
Has the site contact requested a DBH Program follow-up call or email? ___ Yes ___ No
If yes, please describe:
Revised 2/22/2017