few Jersey ay v RS COUN 690 35 Counseling Program .cticum) Internship Site supervisor’s Mid-Term Evaluation (Completed by Site Supervisor) Student's Nam Date_s| Site Location, Site Supervisor. hem Interaship _] L STUDENT PROGRESS Tn what areas has the student intern shown strengths? a Alfa coger fe were carte Chenty ant Families. She ir enqagyy BAM brine promi a Snfyesiatt« | Tin what areas has the student showed improvement? Tr her ability Lt derrtO the Pounchin of ctor Tn what areas (populations, sites, skills, issues) would the student intern be most effective? Lh wer ieny wits ull diverre Pepeehe s (© This document may be reproduced for personal use only. It may not be reproduced or transmitted in any form, or by any means, for any ‘other purpose, without the writen the written permission of the author, who isthe copyright holder ofthis document. For permission to use or quote, in whole or in part, please contact Counseling Department, NICU. “Template Revised 06-19-12COUN 690 36 1 Strongly Disagree 2 Disagree 3 Agree 4Strongly Agree N/A Not Applicable A score of 3 means that you are functioning at the expected level Il, STUDENT’S PROFESSIONAL SKILLS 1. Accepts supervisor's feedback i 2 wa 2. Maintains client confidentiality 12 wa 3. Practices ethical behavior i nla 4, Maintains appropriate case notes and records 1.2 tla 5. Implements goals and policies of the site fi 2 wa 6, Identifies own strengths and weaknesses i 2 wa 7. Works effectively with other professionals 1 2 nla IL STUDENT’S COUNSELING SKILLS 1. Responds appropriately to client 1 0203 2. Establishes rapport 1 2 3 © @ 3. Is sensitive to individual differences 1 02003 & wa & © 4, Reflects client's feelings 10203 nla 5. Listens effectively 102003 n/a 6. Helps client establish appropriate goals 1 2 @ oa 7. Uses effective interventions consistent with 1 2 Gia m ‘© Ths document may be reproduced for personal use only. It may not be reproduced or transmitted in eny form, or by any means, for any ‘other purpose, without the written the writen permission ofthe author, who isthe copyright holder of this document. For permission to use ‘or quote in whole or in par, please contact Counseling Department, NICU. ‘Template Revised 06-19-12COUN 690 37 theoretical orientation IV-A. SCHOOL COUNSELING ONLY 1 Works effectively in the schoo! setting 1 2 3 4 oe 2.Addresses students’ academic, personal, and 1203 4 oe career needs appropriately. 3.Colabormts| and consults with teachers 1 02 3 4 ne 4.Addresses developmental needs of students 12030 4 oe appropriately at this school level (e.g. college planning, behavior, peers, academic skills) 5. Consults effectively with parents 1002030 4 oe IV-B. MENTAL HEALTH COUNSELING ONLY 1. Conducts intakes and discharges effectively 2) @ 4 la 2. Conceptualizes cases using effective diagnosis 1 2 @ 4 nla and treatment planning. 3. Integrates new session information into ongoing 12 @ a a) ‘treatment planning. Cee ee eee eee 5. Addresses and corrects clinical errors. 1 2 3 @ om 6. Balances responsibilities 1 2 3 @ wa e.g. sessions, appointments, record-keeping, ‘treatment plans, supervision, and unexpected events Topi ‘comment please do so on a separate paper Site Supervisor's Signature WaT Date Bek © This document may be reproduced fr personal use only. It may not be reproduced or transmitted in any form, or by any means, for any ‘other purpose, without the writen the writen permission ofthe author, who isthe copyright holder of this document. For permission to use or quote, in whole or in part, please contact Counseling Department, NICU. ‘Template Revised 06-19-12COUN 690 41 Counseling Program Grasticun aternship Site Supervisor's Final Evaluation (Completed by Site Supervisor) Student's Name, 1G RP2._Date er WA Loca ite eae hw Internship _I Semester Wa Year I. STUDENT PROGRESS Tn what areas has the student intern shown strengths? Bike bes demesivoteD coll i 2 | beern Gnd es Pen 4e | _ J} In what student jntern showed mene : rence CF Sed Te ode bie eae pt bV Veale "Bieonicy Tin what areas (populations, sites, skills, issues) would the student intern be most effective? ee eee with dtuerse Ep fen | (© This document may be reproduced for personal use only. It may not be reproduced or transmitted in any form, or by any means, for any ‘other purpose, without the written the written permission of the author, who is the eopyright holder ofthis document. For permission to use ‘or quote, in whole or in par, please contact Counseling Department, NICU. Template Revised 06-19-12COUN 690 42 1 Strongly Disagree 2Disagree 3 Agree 4Strongly Agree N/A Not Applicable A score of 3 means that you are functioning at the I, STUDENT’S PROFESSIONAL SKILLS 1. Accepts supervisor's feedback 1 2 3 wa 2. Maintains client confidentiality 1 2 nla 3. Practices ethical behavior 1 2 3 na 4, Maintains appropriate case notes and records 1 2 @ wa 5. Implements goals and policies of the site 1 2 3 wa 6. Identifies own strengths and weaknesses 1 2 3 7. Works effectively with other professionals = 2 3 na IIL STUDENT’S COUNSELING SKILLS 1. Responds appropriately to client 23 wa 2. Establishes rapport 1 203 wa 3. Is sensitive to individual differences 1 2 3 wa ©eo OEO-CCO 4, Reflects client's feelings 1 2 @ 4 ms 5. Listens effectively 10203 @s wa 6. Helps client establish appropriate goals Vs 2 G3) 4 2 oe 7. Uses effective interventions consistent with 1 2 @ 4. wa ‘© This document may be reproduced for personal use only. Itmay not be reproduced or transmitted in any form, or by any means, for any other purpose, without the written the written permission of the author, who is the copytight holder of this document For permission to use ‘or quote, i whole or in par, please contact Counseling Department, NICU. ‘Template Revised 06-19-12COUN 690 43 theoretical orientation IV-A. SCHOOL COUNSELING ONLY a kk 1 Works effectively in the schoo! setting 2.Addresses students’ academic, personal, and 1020 30 4 a career needs appropriately. 3.Collaborates and consults with teachers 1 20 3 4 na 4.Addresses developmental needs of students 102003 4 la appropriately at this school level (e.g. college planning, behavior, peers, academic skills) 5. Consults effectively with parents 1 203 4 oe 1V-B. MENTAL HEALTH COUNSELING ONLY 1. Conducts intakes and discharges effectively 1 2 @ 4 wa 2. Conceptualizes cases using effective diagnosis ie Gy 4 nla and treatment planning. 3. Integrates new session information into ongoing 1 203 na @ treatment planning, 4, Works effectively with a range of client problems 2 © ala 5. Addresses and corrects clinical errors. 1 23 ® 6. Balances responsibilities 1 2 3 4 e.g, sessions, appointments, record-keeping, treatment plans, supervision, and unexpected events Site Supervisor's Signature essay tn pc lay, oy hat pe tino hy ya by ther purpose, without the writen th written pemission of the euthor, who i the copyright holder of this document. For permission to use for quote, in whole an par, please contact Counseling Departmen, NICU. ‘Template Revised 06-19-12GHlinaky 4 * Counseling Program Internship Student’(Sfid-Terp? or Final Evaluation (Circle One) (Completed by Site Supervisor) Student's Name, Pyle Rebrigee Date logs& Site Location The (by idge Site Supervisor “Jc ae lewe, tnemsbip nm seneser_ faICUOK Yen Jol 6 I STUDENT PROGRESS Tn what hhas the student shqwn strengths? c areas has the ine ar Seng? fy beak & Lexfe Od Ema pCa Suuredizing |: facts Ste Cheats he 5 Se een showed improvement? asg «i me, pe depenstoFs Clint OC . me fe beth fue ob eche the abi( (pe Cohrs her cSES + cal Tn what areas (populations, sites, skills, isis ‘would the student jntern be most effective? She 33 increcda$ hee cedcz wife addescen - “b 6 “COUN 694 1 Strongly Disagree 2Disagree 3 Agree 4 Strongly Agree A score of 3 means that you are functioning at the expected level Il. STUDENT’S PROFESSIONAL SKILLS 1. Accepts supervisor's feedback 1 2. Maintains client confidentiality 1 3. Practices ethical behavior, 1 4, Maintains appropriate case notes and records 1 5, Implements goals and policies of the site 1 1 6, Identifies own strengths and weaknesses - 1 7. Works effectively with other professionals 1 IIL STUDENT’S COUNSELING SKILLS 1. Responds appropriately to client 1 2. Establishes rapport 1 3. Is sensitive to individual differences 1 4, Reflects client’s feelings 1 5, Listens effectively 1 6, Helps client establish appropriate goals 1 7. Uses effective interventions consistent with 1 theoretical orientation ‘N/A Not Applicable 2 3 Ff 2 3 2 3 2 3 203 223) 2 3 203 2003 2 © GOeO0e OG BOS ) 1 OE -@ nia 4748 COUN 694 IV-A. SCHOOL COUNSELING ONLY 1. Works effectively in the school setting 1 2 3 4 Gr 2.Addresses students’ academic, personal, and 1 2 3 4 le career needs appropriately. 3.Collaborates and consults with teachers 1 2 3 4 Ome 4.Addresses developmental needs of students 1 2 3 4 (a appropriately at this school level (e.g. college planning, behavior, peers, academic skills) 5. Consults effectively with parents 02s @) IV-B. MENTAL HEALTH COUNSELING ONLY 1. Conducts intakes and distharges effectively 1 2 and treatment planning, 3. Integrates new session information into ongoing a2 ® 2. Conceptualizes cases using effective diagnosis 1 2 &) 4 wa treatment planning. 4, Works effectively with a range of client problems 1 0203 ala Addresses and corrects clinical errors. 2 3 &) nla 6. Balances responsibilities 102 (8 \ 42. ma e.g. sessions, appointments, record-keeping, NS treatment plans, supervision, and unexpected events ‘To proyjde additional comment please do so on a separate paper Site Supervisor's Signatur49 COUN 694 New Jersey CITY y RSITY Student Name. Supervisor ) CE (M. levre rhone_P 1 3QOR* IB ure 27 O51 Please respond with a yes/no or brief sentence. 1. What strengths is the student. pen this point in the Cyd b cola Tncreas-eot Cf eng ard lig 2. Is this student progressing at an acceptable rate compatéd with other practicum students or interns? Y i 3. What skill areas pa) “i in individual supervision? What skills should we address? Clint 4, Was this student prepared for the placement? What should be improved? 10. Mee Hesning | horas on aipe 5. Is there anything you need from b ‘Your practicum/internship st after you have discussed it. is evaluation in a sealed envelope to their professor ee linda Vicky, Site Supervisor's Signatur Phone J) 4 DtNEW JERSEY f & “ TY Ve RSITY Counseling Program Internship Student’s Mid-Term, valuation (Circle One) (Completed by Site Supervisor) swicarsNane__HAL (sjuer pa (2 IeE sicteetin Teviegien sin sipnior Jol Hf Vering CoS Internship. G1 mW semester Fell Year_ PIE 1. STUDENT PROGRESS In what areas has the student intern shown strengths? . Pies Les umcveated her Cos clecu wrecks, ff encase . [Tn what areas has the student showed improvement? G pol € i dor iA Sle hes elevre (VE be; jesens & Ch Ashein. [In what areas (populations, sites, skills, issues) weld ‘he student pte bp mo effecey Ds | fla, atc te ST agen, $ form fe bAentti (asCOUN 694 1 Strongly Disagree 2Disagree 3 Agree A score of 3 means that you are functioning at the expected level Il. STUDENT'S PROFESSIONAL SKILLS 1. Accepts supervisor's feedback 2, Maintains client confidentiality 3. Practices ethical behavior 4, Maintains appropriate case notes and records 5. Implements goals and policies ofthe site 6. Identifies own strengths and weaknesses 7. Works effectively with other professionals II]. STUDENT'S COUNSELING SKILLS 1, Responds appropriately to client 2, Establishes rapport 3. Is sensitive to individual differences 4, Reflects client’s feelings 5. Listens effectively 6. Helps client establish appropriate goals 7. Uses effective interventions consistent with theoretical orientation 4 Strongly Agree N/A. Not Applicable ® 4 3 @ >@ © + 1 @ © Oo wv nla Wa nla nla na na 4849 COUN 694 IV-A. SCHOOL COUNSELING ONLY 1.Works effectively in the school setting 1 2 -3- 4 2.Addresses students’ academic, personal, and 1 02 3 4 Cy’ career needs appropriately. 3.Collaborates and consults with teachers 1 2 3 4 4.Addresses developmental needs of students 1 2 3 4 a appropriately at this school level (e.g. college 7 planning, behavior, peers, academic s 5. Consults effectively with parents 1203 4 (nl IV-B. MENTAL HEALTH COUNSELING ONLY 1. Conducts intakes and discharges effectively 12 © 4 aa 2. Conceptualizes cases using effective diagnosis h B @ 4 a and treatment planning. 3. Integrates new session information into ongoing 1 2 @) 4 Wa treatment planning. 4. Works effectively with a range of client problems 1 na @ 5. Addresses and corrects clinical errors. 2) © 6. Balances responsibilities 1 2 i 4 a €.g, sessions, appointments, record-keeping, treatment plans, supervision, and unexpected events To provide additional comment please do so on a separate paper ZU, UR Fue Be Site Supervisor's Signature50 COUN 694 NEW JERSEY CITY Site Supervisor’s Midterm or Final Evaluation for Internship Student Name_ff b 2 Site, — ‘Vel i Le wire Phone_Y Cr Please respond with a yes/no or brief sentence. 1. What strengths is the student demonstrating at this point in the placement? ¥rq _— _ 2. Is this student. a students or interns? ssing at an acceptable rate compared with other practicum Ges 3. What skill areas have you focused on in individual supervision? What skills should we address? De Core Seber pile (dS one 4, Was this student prepared for the placement? What should be improved? G~s 5. Is there anything youneed fom us? fj, after you have discussed it. eae be Email ewe Pelle Site Supervisor’ Signature rone_G73 98%New Jersey cC ITY U RSITY Counseling Program Internship Student’ {(Mid-Terapor Final Evaluation (Circle One) (Completed by Site Supervisor) Date, gf Site Supervisor. Student's Name, Site Location Internship _1_M1 i __Iv Seneses Se Year_20/'7 I. STUDENT PROGRESS 47 [In what areas has the student intern shown strengths? Com wo ite q. ae plactess CVinied y leds I in what areas has the student showed improvement? Pritentim to deb Tn what areas (populations, sites, skills, issues) would the student intern be most effective? Clin od thectsd Health -COUN 694 1 Strongly Disagree 2Disagree 3 Agree 4 Strongly Agree A score of 3 means that you are functioning at the expected level IL, STUDENT'S PROFESSIONAL SKILLS 1. Accepts supervisor's feedback 2. Maintains client confidentiality 3. Practices ethical behavior 4, Maintains appropriate case notes and records 5. Implements goals and policies of the site 6. Identifies own strengths and weaknesses 7. Works effectively with other professionals IIL STUDENT'S COUNSELING SKILLS 1, Responds appropriately to client 2. Establishes rapport 3. Is sensitive to individual differences 4. Reflects client’s feelings 5. Listens effectively 6. Helps client establish appropriate goals 7. Uses effective interventions consistent with theoretical orientation NIA Not Applicable | OO- - COS -- Q0Q00 nla nla ala na nla na Wa‘COUN 694 V | h, IV-A. SCHOOL COUNSELING ONLY L.Works effectively in the school setting 2.Addresses students’ academic, personal, and career needs appropriately. 3.Collaborates and consults with teachers 4,Addresses developmental needs of students appropriately at this school level (e.g. college planning, behavior, peers, academic skills) 5. Consults effectively with parents IV-B. MENTAL HEALTH COUNSELING ONLY 1. Conducts intakes and discharges effectively 2. Conceptualizes cases using effective diagnosis and treatment planning, 3. Integrates new session information into ongoing ‘treatment planning. 4, Works effectively with a range of client problems 5. Addresses and corrects clinical errors. 6. Balances responsibilities €.g, sessions, appointments, record-keeping, treatment plans, supervision, and unexpected events 2 3 4 2 24 2 3 4 2 3 4 To provide additional comment please do so on a separate paper Site Supervisor's Suef | / 2 MCo.An Werpate 3-47 wa nia wa 4950 COUN 694 New Jersey CITY v RSITY Site Sypervis iidterm or Final Evaluation for Internship Student Name i elt eure Phone Please respond with a yes/no or brief sentence. 1, What strengths is the student demonstrating at this point in thg placement? Eagemness , Gmmitre!, aaaaay 2. Is this student progressing at an acceptable rate compared with other practicum students or interns? Yes} wes had Site, 3. What skill areas have you focused on in individual saps? ‘What skills should we address? - Cae Thecretied OpPratch; Fecroot Ie: Tk 4. Was this student prepared for the placement? What should be improved? yes! Fpereoged Lpdherstendiog CF Tntes aby goes wo ‘Your practicum/internship stuglent can brit 5.Is there anything you need Gall is evaluation in a sealed envelope to their professor47 Counseling Program Internship Student's Mid-Term ofan Evalonad}Chee One) oe Oe by Site Supervisor) Student’: vox Pf Rod [gues urr Site Location a “6 -N & Site Supervisor Internship 1 IV Semester ange I. STUDENT PROGRESS. In what areas has the student intern shown strengths? pl fe Way ew ae Ge ar Cees fr these Sne ber ae t Cuemed In what areas has the student showed improvement? hice bes been ve eeptre ‘o elem, ord Viites Eton 1 of Goa! le Led Leah 8 In what areas (populations, sites, skills, issues) would the student intern be most effective? meCOUN 694 1 Strongly Disagree 2 Asscore of 3 means that you are functioning at the expected level IL STUDENT’S PROFESSIONAL SKILLS, 1, Accepts supervisor's feedback i 2. Maintains client confidentiality 3. Practices ethical behavior 4, Maintains appropriate case notes and records 5. Implements goals and policies of the site 6. Identifies own strengths and weaknesses 7. Works effectively with other professionals i Il. STUDENT’S COUNSELING SKILLS 1. Responds appropriately to client 2. Establishes rapport 3. Is sensitive to individual differences \ 4, Reflects client’s feelings 5. Listens effectively 6. Helps client establish appropriate goals 7. Uses effective interventions consistent with ‘theoretical orientation gree 3 Agree 4 Strongly Agree OOOLPRHO OOOVOEO N/A Not Applicable ala naCOUN 694 IV-A. SCHOOL COUNSELING ONLY 1 Works effectively in the school setting 1 203 4 wa 2.Addresses students’ academic, personal, and 1 a a) career needs appropriately. 3.Collaborates and consults with teachers 1 2 3 4 oa 4,Addresses developmental needs of students 1 2 3 4 wa appropriately at this school level (e.g, college planning, behavior, peers, academic skills) 5. Consults effectively’ with parents 1 020 3 4 a r 1. Conducts intakes and discharges effectively 102,03 ; i—\ 2. Conceptualizes cases using effective diagnosis 1 2 (33 CAT” wa ‘and treatment planning, MENTAL HEALTH COUNSELING ONLY nla 3, Integrates new session information into ongoing 1 2 G) 4 a treatment planning. 4, Works effectively with a range of client problems * 1 2 3 &) 5. Addresses and corrects clinical errors.~ 1 2 3 G) na > @) 6. Balances responsibilities 1 2 na e.g, sessions, appointments, record-keeping, treatment plans, supervision, and unexpected events, To provjde additonal comment please do so on a separate paper Ta Wome 9-257? Site Supervisor's Signat50 Site Supervisor’s Midterm or Final Evaluation for Internship Student Name ella Led figcoee Site, Site Supervisor. Phone Date Please respond with a yes/no or brief sentence. 1. What strengths is the student demonstrating at this point in the placement? 2. Is this student progressing at an acceptable rate compared with other practicum students or interns? 3. What skill areas have you focused on in individual supervision? What skills should we address? 4, Was this student prepared for the placement? What should be improved? 5. Is there anything you need from us? Your practicum/intemship student can bring this evaluation in a sealed envelope to their professor after you have discussed it. Thank you! Site Supervisor’s Signature Date. Phone. Email