Intern Performance Evaluation Form printable pdf download

Form J-Internship (page 1 of 3)

Intern Performance Evaluation Form

Student: ________________________________________________ Date_______________________

Supervisor: _____________________________________________ Site _______________________

Term: ____Fall ____Winter ____Spring ____Summer

Intern’s final term at site? __Yes __No

Term in Practicum/Internship Sequence:

First

Second

Third

Fourth or more

This form should be completed by the site supervisor at the end of each term. Four domains of

Intern competence are listed below along with specific items in each domain. Circle the number

to the right of each item that best describes your perceptions of the intern’s skills compared to all

other people you have trained at the same level of professional development. If the current

evaluation is for the intern’s final term at the site, it should be treated as a summative evaluation.

(The term “client” as used herein refers to any person receiving services including students,

parents, teachers or patients.) IO = Inadequate Opportunity to Observe

NR = Not Relevant to the Setting

Clearly

Counseling Skill

Deficient

Adequate

Excellent

Competency

Explains the nature and objectives of counseling

when appropriate.

Conducts a systematic and complete intake

interview

Establishes a working relationship with clients.

Gains client confidence.

Conveys warmth to the client

Conveys competence to the client

Facilitates the client expression of thought and

feeling

Specifies the client problems in concrete terms

Uses a variety of counselor responses.

Responds to client affect.

Helps client explore personal alternatives.

Establishes relevant counseling goals with client.

Balances between implementing planned strategies

and remaining spontaneous in the counseling

session.

Implements an intervention strategy consistent with

client information and goals.

Intern Performance Evaluation Form

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