Supervisee's Name: _____
Supervisor's Name: _____
Semester:  Fall_____  Spring_____  Year_____
Level of Experience:  1st semester practicum_____  2nd semester practicum_____
Date of Evaluation: _____

Scale: NA, Less than Expected Progress, Expected Progress, Above Expected Progress

Categories of therapeutic competence

1. Ability to sustain a therapeutic relationship.
2. Ability to extract relevant clinical data and inferences.
3. Ability to synthesize clinical data (i.e., conceptualize).
4. Ability to select, administer, and interpret psychometric instruments and diagnostic data.
5. Ability to generate conceptually based treatment goals.
6. Ability to articulate one's counseling/psychotherapy orientation.
7. Ability to acquire a deeper working knowledge of relevant theories and to apply different theoretically
based methods and techniques systematically and proficiently.

Preparedness, openness, and self-initiation

1. Demonstration of preparedness in large group, case presentations, small-group supervision, and individual
supervision.
2. Demonstration of interest in self-development as a clinician.
3. Openness and integration of feedback (e.g., strengths and limitations).
4. Appreciation of one's impact on clients, peers, and others.

Professionalism

1. Performance of professional duties and obligations consistent with professional ethics and legal
considerations.
2. Awareness of and appropriate application of ethical principles and codes of conduct as they relate to clients,
colleagues, supervisors, and other professionals.
3. Alertness to and appropriate response to personal problems or issues as they may affect professional
functioning and initiative in seeking appropriate consultation and assistance.

Overall contribution of large-group seminar and discussions

Overall contribution to small-group supervision and discussions

External placement evaluation

General comments

1.  Summary of the supervisee's strengths
2.  Summary of the supervisee's weaknesses
3.  Recommendations for the supervisees to improve his/her counseling
4.  Other comments
5.  Tentative grade: _____

Supervisor signature and date: _____
Supervisee signature and date: _____