STUDENT PRACTICUM & INTERNSHIP EVALUATION FORM

Transcription

1 STUDENT PRACTICUM & INTERNSHIP EVALUATION FORM STUDENT NAME: Please check one: Mid-term evaluation Final evaluation To the student and the supervisor: The principal purpose of this form is to provide feedback both to the student and to the SCCP program about the student s performance in the placement setting. It is understood that within any setting the student will be able to master only a subset of the skills that are listed on this evaluation form. Masters practicum students (one day a week placement) are expected to receive 1 hour of face-to-face supervision each week. Approximately 20% of their time should spent in direct client contact. Doctoral practicum students (two day a week placement) and internship students are expected to receive 2 hours of faceto-face supervision each week. Approximately 25% of their time should be spent in direct client contact. (The direct client contact time is a guideline only.) The SCCP documents relevant to practicum and internship training are: 1) Monitoring of Students Progress 2) Policies and Procedures Regarding Students in Placement Settings (Overview for Students and Supervisors, Conflict Resolution and Due Process Involving the Placement Settings, Guidelines for Problems in Meeting Competency Expectations for the Practicum/Internship) 3) APPIC Guidelines. These documents can be provided on reuest and are available on our program web site at the following address: This evaluation should be filled out jointly and completed twice. The first evaluation is completed half way through the placement. It gives the supervisor an opportunity to identify strengths and weaknesses and help the student set appropriate goals for the remainder of the placement. In a placement that begins in September, the first evaluation should be returned the second week of January. The second (final) evaluation is due at the end of the practicum or internship. For the final evaluation, hours for the duration of the entire placement (not just the second half) must be reported. Both the supervisor and the student must sign the evaluation. The student should keep a photocopy of this evaluation prior to submitting it to: Dr. Nancy Link, C. Psych Clinical Director School & Child Clinical Psychology Program Telephone: (416) x nlink@oise.utoronto.ca Students and supervisors are encouraged to contact the Clinical Director regarding any uestions or concerns about this evaluation or any other aspect of the SCCP clinical program. Updated: 6-Dec-05

2 SUMMARY OF TIME SPENT IN PLACEMENT ACTIVITIES To Be Filled Out By The Student & Reviewed By The Supervisor: In the following section the student is asked to calculate the amount of time spent in each of three types of activities: 1. Supervision 2. Direct Service (face-to-face contact with clients/patients) 3. Indirect Service (clinically relevant activities that are neither supervision nor direct service) The categories that are provided are guidelines only. What is important is the student and the supervisor achieve a description that most fairly reflects the activities of the student. In some cases a clinical activity can be scored in two categories. For example, if the clinical student and the supervisor assess a child together (both in the room together with the child), this could be classified either as face to face supervision or direct service. In cases such as this, score in only one category. SUPERVISION (Please indicate the number of hours for each of the following): Hours spent in one-on-one, face-to-face supervision: Hours the supervisor edited the student s written work or viewed video tapes outside of supervision: Hours spent in group supervision: Hours spent in peer supervision / consultation and case discussion on specific cases: Number of hours of supervision: DIRECT SERVICES Psychological Assessment Total # of hours 1 Interview/history taking Observation based assessment Individual testing-infant/toddler Individual Testing pre-schooler Individual testing - school age child Individual testing -adolescent Individual testing - adult Assessment feedback to parent(s) and/or students face-to-face Number of different 2 individuals, couples families & groups Total # of Psychological Assessment Hours: 2

3 Educational Intervention Total # of hours 1 Individual remediation Small group teaching Other (specify) face-to-face Number of different 2 individuals, couples families & groups Total # of Education Intervention Hours: Psychotherapy Intervention Total # of hours 1 Infant/toddler(dyadic) Pre-school (individual play) School Age (individual) Adolescent (individual ) Adult (individual) Other (specify) Couples (count as one unit) Family therapy (count as one unit) Group therapy (count as one unit) Parents of a child (count as one unit) Other (specify) face-to-face Number of different 2 individuals, couples families & groups Total # of Psychotherapy Intervention Hours: 1 An hour defined as a clock hour plus or minus 10 minutes 2 Count a couple, family, or group as one unit, rather than counting a couple as two or a group as seven. Total # of Intervention Hours (Educational Intervention + Psychotherapy Intervention hours): TOTAL # OF DIRECT SERVICE HOURS (INTERVENTION + PSYCHOLOGICAL ASSESSMENT) (Round this off to the nearest whole number): INDIRECT SERVICES Number of practicum hours the student spent in activities supporting psychological assessment, examples of activities in this category include: Observing other professionals testing Consulting with teachers and other professionals, case conferences, team meetings (include class hours spent listening to classmates assessment plans and formulations; interviews with teachers, principals and other professionals regarding your client) Reviewing files, learning about tests, reviewing video tapes of assessment sessions Scoring, interpreting and writing reports Attending lectures, conferences etc specifically related to your specific case(s) (practicum course work is not included here). Total: 3

4 Number of practicum hours the student spent in activities supporting direct intervention (remediation or therapy). Examples of activities in this category include: Observing other professionals doing therapy, Chart/file review, Consulting with other professionals about cases, case conferences, team meetings (the giving and receiving of consultation for example team discussion of cases, time spent in class discussing cases can be included here) Reading literature relevant to ongoing cases (reading & research regarding intervention and remediation) Reviewing video/audio tapes of cases, Attending lectures, conferences etc. Total: Number of hours spent in other clinically related activities (e.g., preparing material for a staff presentation) Total: TOTAL # OF INDIRECT SERVICE HOURS: TOTAL NUMBER OF HOURS OF CLINICAL EXPERIENCE: (Supervision + Direct Service + Indirect Service) 4

5 CLIENT DEMOGRAPHIC PROFILE Gender Number of Males Number of Females Language Transgendered ESL/ESD French Immersion Ethnicity Black/ African Origin Asian Origin/ Pacific Islander Latino- /Hispanic Middle Eastern Canadian Indian/Alaska Native/ Aboriginal European Origin/White Biracial/Multi -racial Other (specify) Sexual Orientation (Please indicate only for those clients where this information is known) Heterosexual Gay Lesbian Bisexual Other (specify) Age of Clients 0-2 years 3-5 years 6-12 years years years 65 + years Disabilities Physical/ Orthopedic Disability Blind/ Visually Impaired Deaf/ Hearing Impaired Learning/ Cognitive Disability Developmental Disability (including Mental Retardation and Autism) Serious Mental Illness (e.g., primary psychotic disorders, major mood disorders that significantly interferes with adaptive functioning) Total Number of Clients: Presenting problems and/or diagnoses of your cases: 5

6 Student Performance Evaluation To be filled out by the supervisor The supervisor may choose one of two reference groups against which to compare the student s performance: The supervisor may wish to compare the students performance with that of fully ualified clinicians. Using this ranking, it is assumed that fully ualified clinicians will generally be in Performance Levels 4 and 3 The supervisor may wish to compare the student s performance with that of other students at the same level Indicate which reference group you are using: (check one) Fully ualified clinicians: Other students at the same level: The following generalized statements of performance are intended to serve as guides in the selection of the appropriate Performance Level. Level 5 Exceptional performance for level Students who produce the highest uality of results. Generally these students can be given difficult or complex assignments with confidence in their ability to apply intelligence and imagination. Students at this level consistently display initiative and achieve results. Their performance is recognizably and decidedly better than a very large proportion of other students. Level 4 - Above average performance for level Performance of students in this category is decidedly better than the normal reuirement. They consistently exceed the normal reuirements in most of their clinical duties. Level 3 Meets expectation for level Most students will meet the normal reuirements of the placement setting and a fairly large proportion will probably remain at this level. The performance of students at this level ranges from meeting normal reuirements to exceeding normal reuirements. Level 2 Needs some improvement Performance is below average and may be erratic or unpredictable. A student whose performance is consistently evaluated at this level should be recommended for an extension of his/her practicum or internship reuirement. Level 1 Needs considerable improvement Consistently performs poorly and clearly needs improvement. A specific period of time should be established for a student to improve his/her performance. If improvement is not made, and performance remains at a poor level, then the student's suitability for this field of work should be re-evaluated. IB - Insufficient Basis for Making a Rating This rating should be used when: (a) the target activities are not typically carried out at the field placement; (b) the student has not engaged in the target activities; (c) a previous supervisor is unavailable for consultation; or (d) the supervisor has not had the opportunity to observe and evaluate the student 6

7 1 = Needs considerable improvement 2 = Needs some improvement 3 = Meets expectations for level 4 = Above average performance for level 5 = Exceptional performance for level IB = Insufficient basis for rating 1. PROFESSIONAL BEHAVIOUR/INTERPERSONAL RELATIONSHIPS Work Habits Is punctual Plans work thoroughly Manages time effectively Makes efficient use of supervision time Ability to generate new, useful ideas Able to work independently Comes to supervision well-prepared and able to use time effectively Decision Making Capable of making difficult or nonroutine decisions Recognizes own limits and appropriately seek the advice of others when needed Assumptions of Responsibilities Takes charge of situations and gets things done Meets deadlines promptly Perceives problem situations and deals with them effectively Interpersonal Skills Gets along and works well with others Ability to work collaboratively with school and/or mental health professionals Has an appropriately professional demeanour 7

8 1 = Needs considerable improvement 2 = Needs some improvement 3 = Meets expectations for level 4 = Above average performance for level 5 = Exceptional performance for level IB = Insufficient basis for rating Is aware of personal issues as they impact on clinical work Deals with personal crises in a way that does not interfere inappropriately with clinical work Responds appropriately to constructive criticism and supervision Oral communications Written communications Comments: 2. ASSESSMENT AND EVALUATION SKILLS Ability to establish rapport with patients/clients Sensitivity to multicultural issues and the range of diversity (e.g. gender, socioeconomic) Insight into client difficulties Interviewing skills (e.g., clinical, intake) Observational skills Ability to formulate appropriate uestions to be addressed by assessment Selects appropriate tests for assessment Breadth & knowledge regarding assessment materials Accuracy and skill in administering and scoring tests Ability to interpret & integrate assessment findings Knowledge and application of diagnosis Ability to relate assessment findings to recommendations 8

9 1 = Needs considerable improvement 2 = Needs some improvement 3 = Meets expectations for level 4 = Above average performance for level 5 = Exceptional performance for level IB = Insufficient basis for rating Quality of written reports Effectively communicates results of assessment to clients and/or relevant others Client file management (e.g., produces appropriate notes and records for client files) Comments: 3. INTERVENTION AND CONSULTATION Ability to establish rapport with patients/clients Sensitivity to multicultural issues and the range of diversity (e.g. gender, socioeconomic) Insight into client difficulties Interviewing skills (e.g., clinical, intake) Observational skills Knowledge of psychoeducational intervention techniues Ability to apply psychoeducational intervention techniues Knowledge of psychotherapeutic intervention techniues Ability to apply psychotherapeutic intervention techniues 9

10 1 = Needs considerable improvement 2 = Needs some improvement 3 = Meets expectations for level 4 = Above average performance for level 5 = Exceptional performance for level IB = Insufficient basis for rating Keeps appropriate records of therapy/intervention progress Evaluates ongoing progress during therapy/intervention Client file management (e.g., produces appropriate notes and records for client files) Comments: 4. RESEARCH Participates in established research projects Identifies and develops research ideas relevant to setting Participates in program evaluation Demonstrates awareness of ethical standards for conducting psychological research Research planning and design Comments: 10

11 1 = Needs considerable improvement 2 = Needs some improvement 3 = Meets expectations for level 4 = Above average performance for level 5 = Exceptional performance for level IB = Insufficient basis for rating 5. ETHICS Familiarity with ethical standards for psychologists, understands their implications, and acts accordingly Demonstrates responsibility to clients, society, the profession and colleagues Demonstrates knowledge of jurisprudence and local regulations Awareness of and ability to deal appropriately with professional biases and beliefs including such issues as gender, race, cultural bias, classism and homophobia Demonstrates knowledge of factors that may influence the professional relationship (e.g., boundary issues) Deals appropriately with ethical dilemmas Demonstrates familiarity and appreciation of confidentiality issues Demonstrates knowledge of standards for psychological tests, measurements and intervention Is aware of personal limitations Comments: 11

12 THE FOLLOWING QUESTIONS SHOULD BE ANSWERED BY THE STUDENT: 1. What were the student s goals at the beginning of the placement? 2. Student Comments: THE FOLLOWING QUESTIONS SHOULD BE ANSWERED BY THE SUPERVISOR: 1. What progress has this student made towards his/her goals? 2. Please comment on the student s strengths and areas for further development. 3. Do you have any recommendations for future training for this student? 4. Additional Supervisor Comments: 12

13 SCHOOL & CLINICAL CHILD PSYCHOLOGY PROGRAM PRACTICUM / INTERNSHIP SUMMARY NAME OF STUDENT: Telephone number: PROGRAM:(check one) MA practicum Ph.D. practicum Half time internship Full time internship Other (specify) Name of Supervisor: Telephone # (work): Placement Name: address: Period covered by this evaluation: From: To: (NB: For the final evaluation, report for the entire duration of the placement) SUPERVISION During this period # of hours of: Face-to-face supervision with the supervisor Other supervision TOTAL # OF SUPERVISION HOURS: DIRECT SERVICE During this period.# of hours of: Psychological Assessment Intervention TOTAL # OF DIRECT SERVICE HOURS: INDIRECT SERVICE TOTAL # OF INDIRECT SERVICE HOURS: TOTAL # OF HOURS OF CLINICAL EXPERIENCE: (Supervision + Direct Service + Indirect Service): Signature of Supervisor Signature of Student Date Date NOTE: Student should make a copy of this for their records prior to submitting it to the Clinical Director. 13