Applied II/Internship
Student Counselor Evaluation Form
Applied II/Internship
Student Counselor Evaluation Form
This evaluation form is to be completed at various points during the students Applied II and Internship placements. It should be completed by the on-site supervisor at the mid-point or at the end of a student's placement. The supervisor will discuss this evaluation with the student counselor.
Name of Student Counselor_____________________________
Name of Field Site____________________________________
Name of site Supervisor________________________________
Term or period covered by this evaluation__________________
Course (circle one): Applied Practices II Internship
Rating Scale:
4-Outstanding3-Very Good
2-Adequate
1-Unsatisfactory
0-Not observed
1. Personal/Professional characteristics
A. Sensitivity to
others 4 3 2 1 0 B. Personal
Appearance 4 3 2 1 0 C. Ability to accept
other's values 4 3 2 1 0 D. Awareness of own
strengths/weaknesses 4 3 2 1 0 E. Openess to growth and
learning 4 3 2 1 0 F. Overall professional
demeanor 4 3 2 1 0
Comment on personal/professional demeanor:
2. Student counselors communication and coordination skills
A. Able to communicate
with others 4 3 2 1
0 B. Works cooperatively
with others 4 3 2 1 0 C. Able to bring about
changes in the setting 4 3 2 1 0 D. Able to consult with
others while maintaining confidences
of the client 4 3 2 1 0 E. Able to convey
information orally and
in written form 4 3 2 1 0 F. Accepts and completes
assigned tasks 4 3 2 1 0 G. Able to establish and
maintain a positive and professional working alliance with
other staff 4 3 2 1 0
Comment on communication and coordination skills:
3. Counseling Skill:
A. Behaves ethically and
maintains confidences 4 3 2 1 0 B. Aware of own personal
and professional
limitations 4 3 2 1 0 C. Able to apply
knowledge to counseling and/or client
situations 4 3 2 1 0 D. Responds appropriately
to clients 4 3 2 1 0 E. Assumes leadership in
counseling sessions 4 3 2 1 0 F. Is perceptive in
handling client cues 4 3 2 1 0 G. Accepts and respects
the client 4 3 2 1 0 H. Conveys a pleasant
mood or relaxed atmosphere 4 3 2 1 0 I. Is sincere in working
with clients 4 3 2 1 0 J. Gains confidence of
the client 4 3 2 1 0 K. Is a good
listener 4 3 2 1 0 L. Able to specify client
concerns in a concrete manner 4 3 2 1 0 M. Can develop client
effective awareness through
empathetic responses 4 3 2 1 0 N. Able to facilitate
resolution of concerns
of client 4 3 2 1 0 O. Overall evaluation of
counseling skill 4 3 2 1 0
Comment on counseling skill:
Potential demonstrated by
student counselor
A. To function
with minimal
supervision 4 3 2 1 0 B. For becoming
an effective
counselor 4 3 2 1 0 C. Overall evaluation of
potential as counselor 4 3 2 1 0
Student Counselor Strengths:
Student counselor weaknesses/needs for improvement:
Has this evaluation been discussed with the student counselor? ______Yes _____No
Site Supervisor Signature______________________________ Date____________