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Clinical Services (Online Due to COVID-19)
Professional Education
Research & Resources
Mid-Semester Supervisor Evaluation of Intern
Mid-Semester Supervisor Evaluation of Intern
Semester
*
Please select
Fall
Spring
Academic Year
Your Name
*
Your Email
*
Training Track
*
Mental Health
Clergy
Congregational Systems
Un-licensed Staff
Year in Program
*
First
Second
Third
Fourth
Other
Supervision Format
*
Individual
Dydadic
Group
Status- (please select the status that applies to you)
*
Full-time student
Part-time student
1 hour per week
2 hours per week
Describe the developmental level and major strengths of supervisee.
*
Describe the key areas discussed in supervision.
*
Recommended areas of focus for the remainder of the semester.
*
Discuss any area of concerns.
*
Directions: Please select a rating for each skill area. Rating Scale 1 = Needs improvement – difficulty gaining competency in this skill area 2 = New skill area 3 = Beginner level – basic competency in this area of clinical practice 4 = Intermediate level – effective in this area of clinical practice 5 = Advanced level – very effective in this area of clinical practice NEI = Not enough information
I. CONCEPTUAL & PERCEPTUAL SKILLS (SLO 2.1)
A. Knowledge Base
*
Rating
1
2
3
4
5
NEI
B. Familiarity with Therapy Models
*
Rating
1
2
3
4
5
NEI
C. Awareness of Diversity Issues
*
Rating
1
2
3
4
5
NEI
D. Recognition of Relational Patterns
*
Rating
1
2
3
4
5
NEI
II. EXECUTIVE SKILLS (SLO 2.2)
A. Joining
*
Rating
1
2
3
4
5
NEI
B. Basic Therapeutic Skills
*
Rating
1
2
3
4
5
NEI
C. Assessment
*
Rating
1
2
3
4
5
D. Hypothesizing
*
Rating
1
2
3
4
5
NEI
E. Treatment Planning
*
Rating
1
2
3
4
5
NEI
F. Intervention Strategies
*
Rating
1
2
3
4
5
NEI
G. Integration of Models
*
Rating
1
2
3
4
5
NEI
III. PROFESSIONAL SKILLS (SLO 2.3)
A. Session Management
*
Rating
1
2
3
4
5
NEI
B. Supervision Responsibilities
*
Rating
1
2
3
4
5
NEI
C. Ethical Issues
*
Rating
1
2
3
4
5
NEI
D. Paperwork
*
Rating
1
2
3
4
5
NEI
E. Professional Behaviors
*
Rating
1
2
3
4
5
NEI
IV. EVALUATION SKILLS (SLO 2.4)
A. Evaluation of Therapeutic Progress
*
Rating
1
2
3
4
5
NEI
B. Evaluation of Self as Therapist
*
Rating
1
2
3
4
5
NEI
V. PERSONAL SKILLS (SLO 2.5)
A. Personal Qualities of the Therapist
*
Rating
1
2
3
4
5
NEI
This evaluation has been adapted from: Nelson, T.S. & Johnson, L.N. (1999). The Basic Skills Evaluation Device. Journal of Marital and Family Therapy, 25, 1, 15-30.
Name of Supervisee
*
First
Last
Supervisee Email
*
When you hit submit, a copy of your completed form will be emailed to you and your supervisee to discuss together.