Page 1 of 16 Updated March 2018 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 be spent in direct client contact. Doctoral practicum students (two day a week placement) and internship students are expected to receive 2 hours of face-to-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 following SCCP documents are relevant to practicum and internship training: 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 request and are available on our program website at the following address: http://www.oise.utoronto.ca/aphd/UserFiles/File/Clinic_Forms/SCCP/SCCP_Practicum_Internship_Handbook _Part_1_Mar_2016.pdf 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 (late June or early August). 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. Note: Students should make a copy for their records and also submit a hard copy to the Director of Clinical Training with original signatures. It is optional to also email a copy. Students and supervisors are encouraged to contact the Director of Clinical Training regarding any questions or concerns about this evaluation or any other aspect of the SCCP clinical program. Dr. Mary Caravias, Ph.D., C. Psych. Director of Clinical Training, School & Child Clinical Psychology Program Telephone: (416) 978-0624 Fax: (416)-926-4763 e-mail: [email protected]GENERAL INSTRUCTIONS: • Sections 1, 2, and 4 are to be filled out by the student & reviewed by the supervisor. Section 3 is to be filled out by the supervisor. • Note to students: Please be advised that this form pertains only to program-sanctioned training experiences or program-sanction work experiences. If you have obtained additional, relevant work experience, this can be documented elsewhere (on another form). Department of Applied Psychology & Human Development, OISE School and Clinical Child Psychology Program
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Page 1 of 16 Updated March 2018
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 be spent in direct client contact. Doctoral practicum students (two day a week
placement) and internship students are expected to receive 2 hours of face-to-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 following SCCP documents are relevant to practicum and internship training:
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 request and are available on our program website at
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 (late June or
early August).
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.
Note: Students should make a copy for their records and also submit a hard copy to the Director of Clinical Training with original signatures. It is optional to also email a copy. Students and supervisors are encouraged to contact the Director of Clinical Training regarding any questions or
concerns about this evaluation or any other aspect of the SCCP clinical program.
Dr. Mary Caravias, Ph.D., C. Psych.
Director of Clinical Training, School & Child Clinical Psychology
1. INTERVENTION AND ASSESSMENT EXPERIENCE (DIRECT SERVICES)How much experience do you have with different types of psychological interventions and assessment?
For this question (Question 1), please summarize professional activities that you have provided in the presence of a
client / patient. Activities that pertain to a client / patient but did not take place in the presence of the client / patient
(e.g., gathering information about a client / patient), should be recorded in Question 5 (Support Activities).
When quantifying your practicum experience, you must use your best judgment of the time spent in different activities
and the number of clients / patients seen. If an exact number is not available, please use a best estimate and consult with
your training director as needed.
o A practicum hour should be a full clock hour, not a partial hour. However, a 45-50 minute client/patient
meeting can be counted as a full practicum hour.
o Unless otherwise indicated, please note that the categories are intended to be mutually exclusive; that is, a
practicum hour counted in one section should not be counted in another section as well. Some experiences
might seem to fall under more than one section; however, you must decide which section best captures the
experience and record your time in this section. (For example, a Relaxation group might be classified as a
‘group,’ or a ‘Medical / Health-Related Intervention,’ but not both.)
o When documenting an hour spent with a group of clients / patients (e.g., a couple, family, group), this
should be recorded as one hour in total (i.e., do not count an hour for each separate person in the group).
o In the “# of different…” category, please count a group (e.g., a couple, family, group) as one (1) unit. For
example, if a student met with a group of 10 clients / patients for an hour session over a period of 8 weeks,
this would count as 8 hours and 1 group. A group with open membership is also counted as one (1) unit.
Total hours
face-to-face
# of different
INDIVIDUALS
a. Individual Therapy
1) Older adults (65+)
2) Adults (18-64)
3) Adolescents (13-17)
4) School-Age (6-12)
5) Pre-School (3-5)
6) Infants / Toddlers (0-2)
b. Career Counselling
1) Adults
2) Adolescents
c. Group Therapy
1) Adults
2) Adolescents (13-17)
3) Children (12 and under)
d. Family Therapy
e. Couples Therapy
Page 3 of 16 Updated February 2018
Total hours
face-to-face
# of different
INDIVIDUALS
f. School-Based Interventions
1) Consultation
2) Direct Intervention
3) Other:
g. Other Psychological Interventions
1) Sport Psychology / Performance Enhancement
2) Medical / Health-Related / Interventions
3) Intake Interview / Structured Interview
4) Substance Abuse Interventions
5) Consultation
6) Other Interventions (e.g., milieu therapy,
treatment planning with the patient present)1
Please describe the nature of the experience in g. 6) ‘Other Interventions’:
h. Psychological Assessment Experience: This is the estimated total hours spent administering tests to clients /
patients, face-to-face. Also include in this section the total hours spent providing feedback to clients / patients.
However, do not include time spent scoring tests or report writing; the latter activities can be documented in the
Question 5 (Support Activities). Information about the number of tests scored will be recorded elsewhere (in
Section 2).
PSYCHOLOGICAL ASSESSMENT EXPERIENCE
Total hours face-to-face
1) Psychodiagnostic test administration (include symptom assessment,
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:
Page 16 of 16 Updated February 2018
SECTION 4
SCHOOL & CLINICAL CHILD PSYCHOLOGY PROGRAM
PRACTICUM / INTERNSHIP SUMMARY
NAME OF STUDENT: Telephone number:
PROGRAM:(check one) MA practicum Ph.D. practicum
Additional Ph.D. practicum Half time internship
Full time internship Other (specify)
Name of Supervisor: Placement Name:
Telephone # (work): E-mail address:
Period covered by this evaluation: From: To:
(NB: For the final evaluation, report for the entire duration of the placement)
a. Total Intervention Hours
a. Total Assessment Hours
a. Total Intervention and Assessment Hours
(Question 1)
b. Total Supervision Hours
(Question 2)
c. Total Hours Spent in Support Activities
(Question 5)
TOTAL HOURS OF CLINICAL
EXPERIENCE
(Question 1 + 2 + 5)
Signature of Supervisor Signature of Student
Date Date
Note: Students should make a copy for their records and also submit a hard copy to the Director of Clinical Training with original signatures. It is optional to also email a copy.