Student Intern_____________________________________________

Agency/Organization________________________________________

Site Supervisor____________________________________________

Position of Site Supervisor___________________________________

Period Covered by Evaluation_________________________________

Please use the following numbers to represent the various levels of achievement or competence:
0 - Not applicable
1 - Did not meet minimum performance expectations
2 - Met minimum performance expectations
3 - Met average performance expectations
4 - Met performance expectations to an above average degree
5 - Outstanding competence or accomplishment

A. ON SITE BEHAVIOR
The intern:

1. Became familiar with department or agency functions and procedures.
0 1 2 3 4 5

2. Met agency expectations for dress and grooming.
0 1 2 3 4 5

3. Initiated regular consultations with supervisor and/or other staff concerning internship experiences.
0 1 2 3 4 5

4. Became involved with office activities, e.g. staff meetings, special projects, etc.
0 1 2 3 4 5

5. Was reliable, punctual, responsible and can follow directions when asked.
0 1 2 3 4 5

6. Took full advantage of available opportunities to facilitate learning, e.g. reviewed office literature,
visited other programs, etc.
0 1 2 3 4 5

7. Was prepared for meetings.
0 1 2 3 4 5

B. HUMAN RELATIONS SKILLS
The intern:

1. Exhibited a congruence between what he/she said and what he/she did when dealing with clients and staff.
0 1 2 3 4 5

2. Conveyed ideas and thoughts clearly and articulately.
0 1 2 3 4 5

3 Established open and honest relationships with others.
0 1 2 3 4 5

4. Admitted mistakes and accept responsibility for mistakes
0 1 2 3 4 5

5. Adapted well to new and unexpected situations (flexibility).
0 1 2 3 4 5

6. Displayed tact in expressing his/her views and in eliciting information.
0 1 2 3 4 5

7. Exhibited understanding of and respect for staff and clients alike.
0 1 2 3 4 5

8. Demonstrated ability to listen and attend to what others are saying.
0 1 2 3 4 5

9. Exhibited the ability to handle confidential information appropriately.
0 1 2 3 4 5

10. Demonstrated ability to communicate via writing (reports, letters, etc.).
0 1 2 3 4 5


C. MANAGEMENT/PROGRAMMING SKILLS AND COMPETENCIES
The intern could:

1. Work on his/her own with minimum of supervision.
0 1 2 3 4 5

2. Select and use appropriate materials needed.
0 1 2 3 4 5

3. Be resourceful, innovative and has the ability to apply his/her knowledge to various work situations.
0 1 2 3 4 5

4. Understand the department/unit's role within the large organization.
0 1 2 3 4 5

5. Demonstrate problem-solving.
0 1 2 3 4 5

D. HELPING RELATIONSHIP:
(Impressions based on observations of the general tone set by the intern in his/her contact with clients.)
The intern was able to:

1. Create an atmosphere that is conducive to effective helping.
0 1 2 3 4 5

2. Communicate acceptance and positive regard.
0 1 2 3 4 5

3. Demonstrate accurate empathy.
0 1 2 3 4 5

4. Keep responsible control over the direction of sessions.
0 1 2 3 4 5

5. Appear genuine.
0 1 2 3 4 5

6. Consistently establish a good working relationship with clients.
0 1 2 3 4 5

7. Communicate respect for his/her clients.
0 1 2 3 4 5

8. Be very aware of the relationship dynamics operating in his/her counseling.
0 1 2 3 4 5

9. Treat clients of different gender, age, and cultural backgrounds with respect and understanding.
0 1 2 3 4 5


E. CONCEPTUALIZATION SKILLS:
(Impressions based on observations of the communication skills demonstrated by the intern's behavior).
The intern could:

1. Articulate his/her personal theory of helping.
0 1 2 3 4 5

2. Conceptualize client problems in terms of a consistent sound, personal theory.
0 1 2 3 4 5

3. Identify the need for a specific technique.
0 1 2 3 4 5

4. Discern when clients need more or less structure for maximum growth.
0 1 2 3 4 5

5. Work from a theory consistent to his/her personality, values and basic beliefs.
0 1 2 3 4 5

6. Demonstrate an openness to information and experiences which appear contrary to his/her personal theory.
0 1 2 3 4 5

F. CONSULTATION SKILLS
The Intern:

1. Appeared open to constructive criticism.
0 1 2 3 4 5

2. Was able to ask for help and consultation.
0 1 2 3 4 5

3. Was able to resolve interpersonal difficulties with the supervisor.
0 1 2 3 4 5

G. GENERAL EVALUATION:

Overall evaluation of the student's success in internship, including particular strengths and areaas for improvement. (Please use the back of this page to continue your comments).
0 1 2 3 4 5



Intern's Signature/Date__________________________________________________

Site Supervisor's Signature/Date__________________________________________