Practicum Experiences / Total / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15
Assessment Experiences
Client: Race/ Ethnicity [number, only count 1st time]
African-American/Black/African Origin
Asian-American/Asian Origin/ Pacific Islander.
Latino-a/ Hispanic
American Indian/ Alaska Native/ Aboriginal Canada
European Origin/ White
Bi-racial/ Multi-racial
Other: Specify:
Client: Sexual Orient. [Number, only count 1st time]
Heterosexual
Gay
Lesbian
Bisexual
Other: Specify:
Client: Disability [number, only count 1st time]
Physical/ Orthopedic Disability
Blind/ Visually Impaired
Deaf/ Hard of Hearing
Learning/ Cognitive Disability
Developmental Disability (MR and AUT)
Serious Mental Illness (DSM-IV)
Other: Specify:
Client: Gender [number, only count 1st time]
Male
Female
Transgendered
Supervision Received [hours]
Individual with supervisor(s)
Group supervision with supervisor(s)
Peer supervision/ consultation (case specific)
Support activities [hours]
Chart document/ report writing / outside consults
Research/ intervention planning/ record review
Semester: ______Setting:______ / Weeks
Practicum Experiences / This / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15
Hours spent administering tests
Psycho-diagnostic Tests Administered (hours)
Neuropsychological Tests Administered (hours)
Other: Specify:______(hours)
Number of COMPLETED assessments (all parts)
Psycho-diagnostic (number)
Neuropsychological (number)
Other: Specify:______(number)
Number of the following tests
Achenbach Child Behavior Checklist
Battelle Developmental Inventory (BDI)
Bayley Scales of Infant Development®-2nd Edition (BSID-II)
Beck Youth Inventories
Beery-Buktenica Developmental Test of Visual-Motor Integration, 5th Ed. (Beery VMI)
Behavior Assessment System for Children, 2nd Edition (BASC-II)
Bender-Gestalt
Bracken Basic Concept Scale—Revised (BBCS-R)
Brown Attention-Deficit Disorder Scales (BrownADDScales)
Childhood Autism Rating Scale (CARS)
Children's Depression Inventory (CDI)
Clinical Assessment of Behavior™ (CAB™)
Comprehensive Test of Nonverbal Intelligence (CTONI)
Conners' Rating Scales-Revised (CRS-R)
Developmental Indicators for the Assessment of Learning-Third Edition (DIAL-3)
Devereux Scales of Mental Disorders™ (DSMD™)
Diagnostic Achievement Battery, 3rd Ed. (DAB 3)
Differential Ability Scales (DAS)
Draw-A-Person
Semester: ______Setting:______ / Weeks
Practicum Experiences / This / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15
Expressive One-Word Picture Vocabulary Test, 2000 Ed. (EOWPVT)
Gilliam Asperger's Disorder Scale (GADS)
Gilliam Autism Rating Scale (GARS)
Gray Oral Reading Tests, 4th Ed. (GORT 4)
House-Tree-Person
Kaufman Adolescent and Adult Intelligence Test (KAIT)
Kaufman Assessment Battery for Children, 2nd Edition (KABC-II)
Kaufman Survey of Early Academic and Language Skills (K-SEALS)
Kaufman Test of Educational Achievement, 2nd Edition (KTEA-II)
KeyMath-Revised/NU
Kinetic Family Drawing
Leiter International Performance Scale-Revised (Leiter-R)
Luria Screener
Millon Index of Personality Styles Revised (MIPS® Revised)
Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
NEO Personality Inventory-Revised (NEO PI-R™)
Oral and Written Language Scale (OWLS)
Parenting Stress Index, 3rd Ed. (PSI-3)
Peabody Individual Achievement Test-Revised-Normative Update (PIAT-R/NU)
Peabody Picture Vocabulary Test, 3rd Edition (PPVT-III)
Personality Assessment Inventory™ (PAI)
Piers-Harris Children's Self-Concept Scale, 2nd Edition (PHCSCS-2)
Projective: Sentence Completion
Semester: ______Setting:______ / Weeks
Practicum Experiences / This / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15
Receptive One-Word Picture Vocabulary Test, 2000 Ed. (ROWPVT)
Revised Children's Manifest Anxiety Scales (RCMAS)
Reynolds Adolescent Depression Scale, 2nd Ed. (RADS-2™)
Reynolds Child Depression Scale (RCDS)
Reynolds Intelligence Assessment Scale (RIAS)
Roberts’ Apperception Test for Children (RATC)
Rorschach
Scales of Independent Behavior--Revised (SIB-R)
Social Skills Rating Scale (SSRS)
Stanford-Binet, 5th Edition (SB-5)
State-Trait Anger Expression Inventory-2™ (STAXI-2™)
Structured Diagnostic Interviews
Test of Cognitive Ability (TONI)
Test of Written Language-3rd Ed. (TOWL-3)
The Batería Woodcock-Muñoz-Revisada(Batería-R)
The Bilingual Verbal Ability Tests (BVAT)
Thematic Apperception Test (TAT)
Universal Nonverbal Ability Test (UNIT)
Vineland Adaptive Behavior Scales, Second Edition (Vineland-II)
Wechsler Abbreviated Scale of Intelligence (WASI)
Wechsler Adult Intelligence Scale, 3rd Edition (WAIS–III)
Wechsler Individualized Achievement Test, 2nd Edition (WIAT-2)
Wechsler Intelligence Scale for Children, 4th Edition (WISC-4)
Wechsler Preschool and Primary Scale of Intelligence (WPPSI)
Wide Range Achievement Test, 3rd Ed. (WRAT-III)
Semester: ______Setting:______ / Weeks
Practicum Experiences / This / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15
Woodcock Johnson Tests of Achievement, 3rd Edition (WJ-III: ACH)
Woodcock Johnson Tests of Cognitive Ability, 3rd Edition (WJ-III: COG)
Woodcock Reading Mastery Tests-Revised-Normative Update (WRMT-R/NU)
Woodcock-Muñoz Language Survey-Revised (WMLS-R)
Young Children's Achievement Test (YCAT)
Other:
Other:
Other:
Other:
Other:
Other:
Other Psychological Experiences [hours]
Supervision of other students (intervention/ assessment)
Program development/ Outreach programming
Outcome assessment of programs or projects
Systems Intervention/ Organizational Consultation
Other: Specify: ______
_____
Supervisor’s SignatureStudent’s Signature