Student Practicum & Internship Evaluation Form

STUDENT PRACTICUM & INTERNSHIP EVALUATION FORM

STUDENT NAME:

Please check one:  Mid-term evaluation Final evaluation

TO THE STUDENT AND THE SUPERVISOR:

The principal purpose of this form is to provide feedback both to the student and to the SCCP program about the student’s performance in the placement setting. It is understood that within any setting the student will be able to master only a subset of the skills that are listed on this evaluation form.

Masters practicum students (one day a week placement) are expected to receive 1 hour of face-to-face supervision each week. Approximately 20% of their time should be spent in direct client contact. Doctoral practicum students (two day a week placement) and internship students are expected to receive 2 hours of face-to-face supervision each week. Approximately 25% of their time should be spent in direct client contact. (The direct client contact time is a guideline only.)

The following SCCP documents are relevant to practicum and internship training:

1)Monitoring of Students’ Progress

2)Policies and Procedures Regarding Students in Placement Settings (Overview for Students and Supervisors, Conflict Resolution and Due Process Involving the Placement Settings, Guidelines for Problems in Meeting Competency Expectations for the Practicum/Internship)

3)APPIC Guidelines. These documents can be provided on request and are available on our program website at the following address:

This evaluation should be filled out jointly and completed twice. The first evaluation is completed half way through the placement. It gives the supervisor an opportunity to identify strengths and weaknesses and help the student set appropriate goals for the remainder of the placement. In a placement that begins in September, the first evaluation should be returned the second week of January. The second (final) evaluation is due at the end of the practicum or internship (late June or early August).

For the final evaluation, hours for the duration of the entire placement (not just the second half) must be reported. Both the supervisor and the student must sign the evaluation.

The student should keep a photocopy of this evaluation prior to submitting it to the Directorof Clinical Training. Students and supervisors are encouraged to contact the Director of Clinical Training regarding any questions or concerns about this evaluation or any other aspect of the SCCP clinical program.

Dr. Mary Caravias, Ph.D., C. Psych.

Director of Clinical Training, School & Child Clinical Psychology Program

Telephone: (416) 978-0624

Fax: (416)-926-4763

e-mail:

GENERAL INSTRUCTIONS:

• Sections 1, 2, and 4 are to be filled out by the student & reviewed by the supervisor. Section 3 is to be filled out by the supervisor.

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

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. 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 5 (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.

Total hours
face-to-face / # of different
INDIVIDUALS
a. Individual Therapy
1) Older adults (65+)
2) Adults (18-64)
3) Adolescents (13-17)
4) School-Age (6-12)
5) Pre-School (3-5)
6) Infants / Toddlers (0-2)
b. Career Counselling / Total hours
face-to-face / # of different
INDIVIDUALS
1) Adults
2) Adolescents
c. Group Counselling / Total hours
face-to-face / # of different
GROUPS
1) Adults
2) Adolescents (13-17)
3) Children (12 and under)
d. Family Therapy / Total hours
face-to-face / # of different
FAMILIES
e. Couples Therapy / Total hours
face-to-face / # of different
COUPLES
f. School Counselling Interventions / Total hours
face-to-face / # of different
INDIVIDUALS
1) Consultation
2) Direct Intervention
3) Other:
g. Other Psychological Interventions / Total hours
face-to-face / # of different
INDIVIDUALS
1) Sport Psychology / Performance Enhancement
2) Medical / Health-Related / Interventions
3) Intake Interview / Structured Interview
4) Substance Abuse Interventions
5) Consultation
6) Other Interventions (e.g., milieu therapy,
treatment planning with the patient present)[1]
Please describe the nature of the experience in g. 6) ‘Other Interventions’:

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 5 (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):

1. Other Psychological Experience with Students and / or Organizations:

OTHER PSYCHOLOGICAL EXPERIENCE WITH STUDENTS AND / OR ORGANIZATIONS

Total hours
face-to-face
1) Supervision of other students performing
intervention and assessment activities
2) Program Development / Outreach Programming
3) Outcome Assessment of programs or projects
4) Systems Intervention / Organizational Consultation /
Performance Improvement
5) Other (please specify):

2.SUPERVISION RECEIVED

In Question 2, 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. Didactic portions of training should be documented in Question 5 (Support Activities); e.g., presentations and ‘Grand Rounds’ would generally not be considered to be supervision hours.

• Individual and group supervision are listed separately in the table. Individual supervision is one-on-one, face-to-face supervision.
• Group supervision refers to the discussion of specific cases in a group led by a supervisor (mental health professional).

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 / Total Supervision Hours
a. Individual Supervision Received
b. Group Supervision Received

3.SUMMARY OF PRACTICUM HOURS

This section summarizes the total hours you recorded in Questions 1 and 2, above.

a. Total Interventions and Assessment Hours
(Question 1)
b. Total Interventions Hours
c. Total Assessment Hours
d. Total Supervision Hours
(Question 2)
e. Total Intervention + Assessment + Supervision Hours
(Question 1 + 2)

4.INFORMATION ABOUT YOUR PRACTICUM EXPERIENCES

a. TREATMENT SETTINGS

In the next table, select the treatment setting(s) in which you were involved for your practicum / internship. Then, indicate the number of hours you spent in the setting(s)? Only report hours spent in intervention, assessment, or supervision (see the Summary Table above, in Question 3).

Total Intervention, Assessment, and Supervision Hours
Child Guidance Clinic
Community Mental Health Centre
Department Clinic (psychology clinic run by a department or school)
Forensic / Justice setting (e.g., jail, prison)
Medical Clinic / Hospital
VA Medical Centre
Inpatient Psychiatric Hospital
Outpatient Psychiatric Clinic / Hospital
University Counselling Centre /
Student Mental Health Centre
Schools
Other (please specify):

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, indicate your program-sanctioned experience with diverse populations in therapy / counselling / assessment. Record the number of clients / patients you have worked with who are members of the diverse populations listed in the table below. Additional information can be provided in the space under the table. In the ‘Assessment’ column, please include clients / patients for whom you performed assessments or intake interviews.

For Question 4d, 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

client / patient.

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)[2]:
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

5.SUPPORT ACTIVITIES

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

In Question 5, 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:

Below, please elaborate on your support activities if you would like to highlight any experiences that were unusual or unique (100 words or less).

SECTION 2

1. & 2. 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
Bayley Scales of Infant Development
(Specify version) / Multilingual Aphasia Exam
MMPI-2 RF , MMPI-A / Strong Interest Inventory
TAT
BASC-2 / Parent Report Measures (e.g., CBCL) / Trail Making Test A & B
BRIEF-2 / Personality Assessment Inventory / WIAT-III
Bender Gestalt / Projective Sentences / Sentence Completions / WRAML 2
Benton Visual Retention Test / Peabody Picture Vocabulary Test 4 / 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-III
Dementia Rating Scale-II / Rorschach (Specify scoring system) / WRAT 4
D-KEFS / Rey-Osterrieth Complex Figure / WAIS-IV
Human Figure Drawing / Roberts Apperception Test for Children / Wechsler Memory Scale-IV
Kinetic Family Drawing
Millon Adolescent Clinical Inv. (MACI) / Self-report measures of symptoms / disorders (e.g., Beck Depression Inventory) / Wisconsin Card Sorting Test
Millon Clinical Multi-Axial Inv. III (MCMI) / SCID-II
1. ADULT TESTS
NAME OF TEST / # ADMINISTERED AND SCORED / # OF REPORTS WRITTEN
ADULT TESTS
NAME OF TEST (Continued) / # ADMINISTERED AND SCORED / # OF REPORTS WRITTEN
2. CHILD AND ADOLESCENT TESTS
NAME OF TEST / # 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

SECTION 3

Student Performance Evaluation

Note to supervisors

Please compare the student’s performance with that of other students at the same level.

The following generalized statements of performance are intended to serve as guides in the selection of the appropriate Performance Level.

Level 5 – Exceptional performance for level

Students who produce the highest quality of results. Generally these students can be given difficult or complex assignments with confidence in their ability to apply intelligence and imagination. Students at this level consistently display initiative and achieve results. Their performance is recognizably and decidedly better than a very large proportion of other students.

Level 4 - Above average performance for level

Performance of students in this category is decidedly better than the normal requirement. They consistently exceed the normal requirements in most of their clinical duties.

Level 3 – Meets expectation for level

Most students will meet the normal requirements of the placement setting and a fairly large proportion will probably remain at this level. The performance of students at this level ranges from meeting normal requirements to exceeding normal requirements.

Level 2 – Needs some improvement

Performance is below average and may be erratic or unpredictable. A student whose performance is consistently evaluated at this level should be recommended for an extension of his/her practicum or internship requirement.

Level 1 – Needs considerable improvement

Consistently performs poorly and clearly needs improvement. A specific period of time should be established for a student to improve his/her performance. If improvement is not made, and performance remains at a poor level, then the student's suitability for this field of work should be re-evaluated.

IB - Insufficient Basis for Making a Rating

This rating should be used when:

(a)the target activities are not typically carried out at the field placement;

(b)the student has not engaged in the target activities;

(c)a previous supervisor is unavailable for consultation; or

(d)the supervisor has not had the opportunity to observe and evaluate the student

1. PROFESSIONAL BEHAVIOUR/INTERPERSONAL RELATIONSHIPS

Work Habits

Is punctual / IB / 1 / 2 / 3 / 4 / 5
Plans work thoroughly / IB / 1 / 2 / 3 / 4 / 5
Manages time effectively / IB / 1 / 2 / 3 / 4 / 5
Makes efficient use of supervision time / IB / 1 / 2 / 3 / 4 / 5
Ability to generate new, useful ideas / IB / 1 / 2 / 3 / 4 / 5
Able to work independently / IB / 1 / 2 / 3 / 4 / 5
Comes to supervision well-prepared and able to use time effectively / IB / 1 / 2 / 3 / 4 / 5

Decision Making

Capable of making difficult or non-routine decisions / IB / 1 / 2 / 3 / 4 / 5
Recognizes own limits and appropriately seek the advice of others when needed / IB / 1 / 2 / 3 / 4 / 5

Assumptions of Responsibilities

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

Interpersonal Skills

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
Deals with personal crises in a way that does not interfere inappropriately with 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