student practicum & internship evaluation form · page 1 of 16 updated march 2018 student...

of 16 Updated March 2018

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:

http://www.oise.utoronto.ca/aphd/UserFiles/File/Clinic_Forms/SCCP/SCCP_Practicum_Internship_Handbook

_Part_1_Mar_2016.pdf

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.

Note: Students should make a copy for their records and also submit a hard copy to the Director of Clinical Training with original signatures. It is optional to also email a copy. 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: [email protected]

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).

Department of Applied Psychology & Human Development, OISE

School and Clinical Child Psychology Program

http://www.oise.utoronto.ca/aphd/UserFiles/File/Clinic_Forms/SCCP/SCCP_Practicum_Internship_Handbook_Part_1_Mar_2016.pdf

http://www.oise.utoronto.ca/aphd/UserFiles/File/Clinic_Forms/SCCP/SCCP_Practicum_Internship_Handbook_Part_1_Mar_2016.pdf

of 16 Updated February 2018

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.

o 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.

o 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.)

o 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).

o 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 1 group. A group with open membership is also counted as one (1) unit.

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

1) Adults

2) Adolescents

c. Group Therapy

1) Adults

2) Adolescents (13-17)

3) Children (12 and under)

d. Family Therapy

e. Couples Therapy


Total hours

face-to-face

# of different

INDIVIDUALS

f. School-Based Interventions

1) Consultation

2) Direct Intervention

3) Other:

g. Other Psychological Interventions

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’:

h. 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):

i. 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):

1 In this category, consider including ‘parent counseling’ or interventions to help with parenting skills.


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.

o Individual and group supervision are listed separately in the table. Individual supervision is one-on-one,

face-to-face supervision.

o Group supervision refers to the discussion of specific cases in a group led by a supervisor (mental health

professional).

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

2. 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)

3. 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

Outpatient Clinic / Hospital

Inpatient Hospital

Community Mental Health Centre

University Clinic (psychology clinic run by a department or school)

Forensic / Justice setting (e.g., jail, prison)

VA Medical Centre

Child Guidance Clinic

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


Heterosexual

Gay

Lesbian

Bisexual


2 Consider mentioning work with clients who are learning English (ELL), or children who are enrolled in French Immersion.


DISABILITIES Number of Different Clients / Patients Seen


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)


GENDER Number of Different Clients / Patients Seen


Male

Female

Transgender

4. 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

Please record which instruments you administered and scored in your practicum / internship. Separate tables are

provided for instruments used with adults and children. Do not count practice administrations in the table.

EXAMPLES OF PSYCHOLOGICAL INSTRUMENTS / CHILDREN Autism Spectrum Rating Scale-2

Bayley Scales of Infant Development-3

BASC-3

BRIEF-2

Bender Gestalt

Benton Visual Retention Test-2

Boston Naming Test

California Verbal Learning Test

Children’s Memory Scale (CMS)

Comprehensive Test of Phonological

Processing (CTOPP-2)

Conners 3rd Edition

Dementia Rating Scale-II

D-KEFS

Expressive Vocabulary Test (EVT-2)

Human Figure Drawing

Kinetic Family Drawing

Millon Adolescent Clinical Inv. (MACI-IV)

Millon Clinical Multi-Axial Inv. (MCMI)

Myers-Briggs Type Indicator

Multilingual Aphasia Exam

MMPI-2 RF, MMPI-A

Parent Report Measures (e.g., CBCL)

Personality Assessment Inventory (PAI)

Projective Sentences / Sentence Completions

Peabody Picture Vocabulary Test (PPVT-4)

Projective Drawings (includes Draw-a-

Person Test and Kinetic Family Drawing)

Rorschach (Specify scoring system)

Rey-Osterrieth Complex Figure

Roberts Apperception Test for Children

Self-report measures of symptoms / disorders

(e.g., Beck Depression Inventory,

Multidimensional Anxiety Scale for

Children)

SCID-5

Structured Diagnostic Interviews

Strong Interest Inventory

Thematic Apperception Test

Trail Making Test A & B

WIAT-III

WRAML-2

WISC-V

Woodcock Johnson-III (Ach, Cog)

WPPSI-III

WRAT-5

WAIS-IV

Wechsler Memory Scale (WMS-IV)

Wisconsin Card Sorting Test

1. CHILD AND ADOLESCENT TESTS # ADMINISTERED AND

SCORED

# OF REPORTS WRITTEN

2. ADULT TESTS # ADMINISTERED AND

SCORED

# OF REPORTS

WRITTEN


3. INTEGRATED REPORT WRITING

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:

o Personality assessments (objective, self-report, and/or projective)

o Intellectual assessment

o Cognitive assessment

o 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: Ratings should be based, in part, on direct observation. Scores of "Rarely" and

"Occasionally" are considered problematic. Select the rating that best corresponds to how characteristic the

student’s behaviour is of the competency descriptions below.

Rarely Occasionally Usually Very Often Always Insufficient Basis

Rarely: The student rarely demonstrates mastery of this competence and requires additional course-based

instruction or practical experience to develop this skill. A student who is consistently rated at this level will

need to be reviewed and the student’s suitability for their field of work should be re-evaluated.

Occasionally: The skill is demonstrated occasionally and the student requires extra practice in this

competency prior to beginning internship. A student who is consistently rated at this level should be

recommended for an extension of his/her practicum or internship requirement.

Usually: The skill is usually demonstrated by the student and they should continue to develop this

competency with supervision and/or mentoring.

Very Often: The skill is very often demonstrated by the student and is well developed.

Always: The skill is always demonstrated and the student’s skills in this area are exceptionally strong. The

student could serve as a model to other students in this area.

Insufficient Basis for Making a Rating

(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. PROFESSIONALISM/INTERPERSONAL RELATIONSHIPS

Insufficient

Basis

Rarely Occasionally Usually Very

Often

Always

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

Generates new and useful ideas IB 1 2 3 4 5

Works at an appropriate level of

independence for training level

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

Makes difficult or non-routine decisions IB 1 2 3 4 5

Recognizes own limits and appropriately

seeks 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

Recognizes problem situations and deals

with them effectively

IB 1 2 3 4 5

Interpersonal Skills

Forms and maintains productive and

respectful relationships with clients,

peers/colleagues, supervisors and

professionals from other disciplines

IB 1 2 3 4 5

Negotiates differences and handles

conflict satisfactorily; provides effective

feedback to others and receives feedback

nondefensively

IB 1 2 3 4 5

Communication and physical conduct is

professionally appropriate, across

different settings

IB 1 2 3 4 5

Displays emerging professional identity

as psychologist; uses resources (e.g.,

supervision, literature) for professional

development

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

Comments on professionalism/interpersonal relationships:


2. ASSESSMENT AND EVALUATION SKILLS

Insufficient

Basis


Often

Always

Establishes rapport with patients/clients IB 1 2 3 4 5

Is insightful into client difficulties IB 1 2 3 4 5

Demonstrates good interviewing skills

(e.g., clinical, intake)

IB 1 2 3 4 5

Demonstrates good observational skills IB 1 2 3 4 5

Formulates appropriate questions to be

addressed by assessment

IB 1 2 3 4 5

Selects appropriate tests for assessment IB 1 2 3 4 5

Demonstrates breadth & knowledge

regarding assessment materials

IB 1 2 3 4 5

Accurately and skillfully administers and

scores tests

IB 1 2 3 4 5

Interprets & integrates assessment

findings appropriately

IB 1 2 3 4 5

Demonstrates solid knowledge and

application of diagnosis

IB 1 2 3 4 5

Relates assessment findings to

recommendations

IB 1 2 3 4 5

Produces quality written reports IB 1 2 3 4 5

Effectively communicates results of

assessment to clients and/or relevant

others

IB 1 2 3 4 5

Manages client files effectively (e.g.,

produces appropriate notes and records

for client files)

IB 1 2 3 4 5

Comments on assessment & evaluation skills:


3. INTERVENTION AND CONSULTATION

Insufficient

Basis


Often

Always

Establishes rapport with patients/clients IB 1 2 3 4 5

Is insightful into client difficulties IB 1 2 3 4 5

Demonstrates good interviewing skills

(e.g., clinical, intake)

IB 1 2 3 4 5

Demonstrates good observational skills IB 1 2 3 4 5

Demonstrates knowledge of

psychoeducational intervention techniques

IB 1 2 3 4 5

Applies psychoeducational intervention

techniques

IB 1 2 3 4 5

Keeps appropriate records of

therapy/intervention progress

IB 1 2 3 4 5

Evaluates ongoing progress during

therapy/intervention

IB 1 2 3 4 5

Manages client file effectively (e.g.,

produces appropriate notes and records

for files)

IB 1 2 3 4 5

Comments on intervention & consultation:

4. INTERDISCIPLINARY SYSTEMS

Insufficient

Basis


Often

Always

Demonstrates beginning, basic knowledge

of the viewpoints and contributions of

other professions/professionals

IB 1 2 3 4 5

Demonstrates beginning knowledge of

strategies that promote interdisciplinary

collaboration vs. multidisciplinary

functioning

IB 1 2 3 4 5

Demonstrates knowledge of how

participating in interdisciplinary

collaboration/consultation can be directed

toward shared goals

IB 1 2 3 4 5

Develops and maintains collaborative

relationships and respect for other

professionals

IB 1 2 3 4 5


4. RESEARCH (IF APPLICABLE)

Insufficient

Basis


Often

Always

Participates in research projects IB 1 2 3 4 5

Identifies and develops research ideas

relevant to setting

IB 1 2 3 4 5

Participates in program evaluation IB 1 2 3 4 5

Demonstrates awareness of ethical

standards for conducting psychological

research

IB 1 2 3 4 5

Participates in research planning and

design

IB 1 2 3 4 5

Comments on Research:

5. ETHICS

Insufficient

Basis


Often

Always

Familiar with ethical standards for

psychologists, understands their

implications, and acts accordingly

IB 1 2 3 4 5

Demonstrates responsibility to clients,

society, the profession and colleagues

IB 1 2 3 4 5

Knowledgeable of jurisprudence and local

regulations

IB 1 2 3 4 5

Aware of and able to deal appropriately

with professional biases and beliefs (e.g.,

gender, race, homophobia)

IB 1 2 3 4 5

Knowledgeable of factors that may

influence the professional relationship

(e.g., boundary issues)

IB 1 2 3 4 5

Deals appropriately with ethical dilemmas IB 1 2 3 4 5

Demonstrates familiarity and appreciation

of confidentiality issues

IB 1 2 3 4 5

Knowledgeable of standards for

psychological tests, measurements and

intervention

IB 1 2 3 4 5

Comments on Ethics:


6. INDIVIDUAL AND CULTURAL DIVERSITY

Insufficient

Basis


Often

Always

Monitors and applies knowledge of self as

a cultural being in assessment, treatment,

and consultation

IB 1 2 3 4 5

Applies knowledge of others as cultural

beings in assessment, treatment, and

consultation

IB 1 2 3 4 5

Applies knowledge of the role of culture

in interactions in assessment, treatment,

and consultation of diverse others

IB 1 2 3 4 5

Applies knowledge, sensitivity, and

understanding regarding ICD issues to

work effectively with diverse others in

assessment, treatment, and consultation

IB 1 2 3 4 5

Is sensitive to multicultural issues and the

range of diversity (e.g. gender,

socioeconomic) in assessment

IB 1 2 3 4 5

Is sensitive to multicultural issues and the

range of diversity (e.g. gender,

socioeconomic) in intervention

IB 1 2 3 4 5

Comments on Individual and Cultural Diversity:

7. REFLECTIVE PRACTICE

Insufficient

Basis


Often

Always

Displays broadened self-awareness (i.e.,

self-monitoring, reflection regarding

professional practice, utilization of

resources to enhance reflectivity)

IB 1 2 3 4 5

Effectively participates in supervision in a

truthful, factual, and respectful manner

IB 1 2 3 4 5

The following items are for PhD students only:

Demonstrates broad and accurate self-

assessment of competence (i.e., monitors

and evaluates practice activities;

recognizes limits of knowledge/skills,

seeks means to enhance knowledge/skills)

IB 1 2 3 4 5

Monitors issues related to self-care with

supervisor and understands the central role

of self-care to effective practice

IB 1 2 3 4 5

Comments on Reflective Practice:


THE FOLLOWING QUESTIONS SHOULD BE ANSWERED BY THE STUDENT:

1. What were the student’s goals at the beginning of the placement?

2. Student comments:

THE FOLLOWING QUESTIONS SHOULD BE ANSWERED BY THE SUPERVISOR:

1. What progress has this student made towards his/her goals?

2. Please comment on the student’s strengths and areas for further development.

3. Do you have any recommendations for future training for this student?

4. Additional supervisor comments:


SECTION 4

SCHOOL & CLINICAL CHILD PSYCHOLOGY PROGRAM

PRACTICUM / INTERNSHIP SUMMARY

NAME OF STUDENT: Telephone number:

PROGRAM:(check one) MA practicum Ph.D. practicum

Additional Ph.D. practicum Half time internship

Full time internship Other (specify)

Name of Supervisor: Placement Name:

Telephone # (work): E-mail address:

Period covered by this evaluation: From: To:

(NB: For the final evaluation, report for the entire duration of the placement)

a. Total Intervention Hours

a. Total Assessment Hours

a. Total Intervention and Assessment Hours

(Question 1)

b. Total Supervision Hours

(Question 2)

c. Total Hours Spent in Support Activities

(Question 5)

TOTAL HOURS OF CLINICAL

EXPERIENCE

(Question 1 + 2 + 5)

Signature of Supervisor Signature of Student

Date Date

Note: Students should make a copy for their records and also submit a hard copy to the Director of Clinical Training with original signatures. It is optional to also email a copy.

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