<p> Department of Counseling & Educational Psychology</p><p>STUDENT INTERN EVALUATION OF SITE SUPERVISOR</p><p>COURSE INFORMATION INSTRUCTOR: COURSE: SEMESTER: STUDENT NAME: BANNER ID # ADDRESS: CELL PHONE #: EMAIL ADDRESS: SITE NAME OF AGENCY: ADDRESS: TELEPHONE PHONE #: WEBSITE: SITE SUPERVISOR NAME: DEGREE/CREDENTIALS: TITLE: LICENSE: CONTACT PHONE #: EMAIL ADDRESS: This evaluation is intended to provide feedback regarding the student’s practicum or internship site supervisor. Rate your practicum/internship site supervisor on all applicable items based on your experiences and observations. Please utilize the following key: 1= “not satisfactory”; 2= “below average/minimally satisfactory”; 3= “average/satisfactory”, 4= “above average”, 5= “exceptional”.</p><p>1 . Supervisor assisted me in recognizing the impact that diversity N/A 1 2 3 4 5 and multicultural issues can have on the counseling relationship. 2 . Supervisor helped me better understand the impact of social, N/A 1 2 3 4 5 cultural, and political forces that may affect the lives of my clients. 3 . Supervisor helped me identify appropriate interventions to N/A 1 2 3 4 5 utilize with diverse clients. 4 . Supervisor modeled and helped me maintain ethical behavior N/A 1 2 3 4 5 as outlined by the American Counseling Association. 5 . Supervisor was punctual and prepared for my supervision N/A 1 2 3 4 5 sessions. 6 . Supervisor was available for consultation during times outside N/A 1 2 3 4 5 of regularly scheduled supervision. 7 . Supervisor dedicated sufficient time and energy to observing N/A 1 2 3 4 5 videotapes of sessions, tape processing, and conceptualization of cases. 8 . Supervisor made good use of our supervision time. N/A 1 2 3 4 5 9 . Supervisor offered resource information when I requested it. N/A 1 2 3 4 5</p><p>Revised 07/10/16 1 1 0 . Supervisor monitored all case N/A 1 2 3 4 5 materials and client’s progress on a weekly basis. 1 1 . Supervisor was knowledgeable N/A 1 2 3 4 5 about the site in which I worked and shared that information with me. 1 2 . Supervisor demonstrated expertise N/A 1 2 3 4 5 with a wide range of client problems and knowledge of a variety of theoretical approaches and therapeutic interventions. 1 3 . Supervisor maintained N/A 1 2 3 4 5 confidentiality pertaining to information discussed during supervisory sessions. 1 4 . Supervisor provided a supportive N/A 1 2 3 4 5 environment for me to discuss any challenges or triumphs. 1 5 . Supervisor encouraged me to be N/A 1 2 3 4 5 reflective and helped me develop increased skill in critiquing and gaining insight from my counseling tapes, case conceptualizations, and/or counseling sessions. 1 6 . Supervisor provided me with N/A 1 2 3 4 5 constructive feedback related to my areas of growth. 1 7 . Supervisor assisted me in identifying N/A 1 2 3 4 5 my areas of strength. 1 8 Supervisor provided me with useful N/A 1 2 3 4 5 feedback when I did something well. 1 9 . Supervisor gave me useful feedback N/A 1 2 3 4 5 when I did something wrong. 2 0 . Supervisor gave me appropriate N/A 1 2 3 4 5 feedback related to intake. 2 1 . Supervisor gave me appropriate N/A 1 2 3 4 5 feedback related to diagnosis and treatment planning. 2 2 . Supervisor provided me with N/A 1 2 3 4 5 appropriate feedback related to assessment and goal setting. 2 3 . Supervisor encouraged me to utilize N/A 1 2 3 4 5 Department of Counseling & Educational Psychology</p><p> different techniques and interventions when appropriate. 2 4 . Supervisor helped me identify N/A 1 2 3 4 5 concrete goals for myself during the practicum/internship experience. 2 5 . Supervisor assisted me in identifying N/A 1 2 3 4 5 the impact that I have on the counseling process. 2 6 . Supervisor provided me the freedom N/A 1 2 3 4 5 to develop my own counseling style. 2 7 . Supervisor encouraged me and N/A 1 2 3 4 5 helped me learn about additional counseling theories, interventions, or strategies. 2 8 . Supervisor made me feel like he/she N/A 1 2 3 4 5 accepted me and respected me as a person. 2 9 . Supervisor was attentive to both my N/A 1 2 3 4 5 needs and the needs of my clients. 3 0 . Supervisor demonstrated a N/A 1 2 3 4 5 willingness and ability to deal with my personal dynamics when it was relevant to my counseling. 3 1 . Supervisor provided me with N/A 1 2 3 4 5 continuous feedback based on direct observation of my work. 3 2 . Supervisor applied fair criteria in N/A 1 2 3 4 5 evaluating my counseling skills and overall practicum/internship performance. COMMENTS</p><p>Please describe your supervisor’s notable strengths: ______</p><p>Revised 07/10/16 3 ______</p><p>Please describe any areas that need improvement: ______</p><p>*Attach an additional page if necessary. SIGNATURES</p><p>Instructor:______Date:______</p><p>Student:______Date:______</p>