Form I-4 Intern Student'S Site Evaluation

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FORM I-4
INTERN STUDENT’S SITE EVALUATION
Name
Faculty Supervisor
On-site Supervisor
Dates: From Month
Day
Year
to Month
Day
Year
Agency/School
Based on your experiences at this site, circle the appropriate responses.
Agree
Agree
Not
Disagree Sometimes Fully
Appl
A. While at this site, I was:
1. Given clients at the beginning of training
1
2
3
NA
2. Given a sufficient number of clients
1
2
3
NA
3. Given appropriate clients for my skill level
1
2
3
NA
4. Able to obtain group counseling experience
1
2
3
NA
5. Able to tape sessions without difficulty
1
2
3
NA
6. Given sufficient orientation to the site's policies and procedures
1
2
3
NA
7. Given regular supervision (at least once weekly)
1
2
3
NA
8. Given access to additional supervision as necessary
1
2
3
NA
9. Expected to conform to a particular approach(s)
1
2
3
NA
(identify: _______________________________________)
10. Treated with respect by my on-site supervisor
1
2
3
NA
11. Treated with respect by other staff members
1
2
3
NA
B. I would recommend this site to other HDC students.
1
2
3
NA
Signed _____________________________________________ Date _________________________
Student Signature
Return to:
Faculty Supervisor
University of Illinois at Springfield
P.O. Box 19243
Human Development Counseling Program
Springfield, IL 62794-9243

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