Wright State University
School of Professional Psychology
QUARTERLY PROGRESS REPORT
PSI 997, SUPERVISED EXPERIENCE
Trainee: ________________________________________
Report Period: From ______________ to ___________ Quarter: F W Sp Sum Year:_______
Practice Site: _______________________________________________________________________
Supervisor: _______________________________ Liaison: ________________________________
Please circle current curriculum enrollment year: 1 2 3 4 5
Methods Used for Supervision. Check all that apply
__Student Verbal Report __Student Notes or Report __Video Tape __Audio Tape __Co-Therapy
__Live Supervision Other (Please Specify)____________________________________________________
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If more space is needed for comments, attach a separate sheet of paper.
A. Relationship
1. Ability to establish rapport. N/A 1 2 3 4 5
2. Ability to establish and maintain a therapeutic alliance. N/A 1 2 3 4 5
3. Awareness of client’s overt behavior and affect. N/A 1 2 3 4 5
4. Responses to client’s overt behavior and affect. N/A 1 2 3 4 5
5. Maintenance of appropriate professional boundaries. N/A 1 2 3 4 5
Mean Category Level:
B. Diversity
1. Ability to maintain rapport and therapeutic alliance with diverse populations N/A 1 2 3 4 5
2. Awareness of impact of self on others. N/A 1 2 3 4 5
3. Consideration of individual/cultural differences in case conceptualizations. N/A 1 2 3 4 5
4. Initiates diversity issues in supervision N/A 1 2 3 4 5
5. Displays sensitivity to individual and cultural issues in relationship with peers, N/A 1 2 3 4 5
colleagues and staff.
Mean Category Level:
C. Assessment
1. Is able to identify client issues. N/A 1 2 3 4 5
2. Appropriately assesses level of risk N/A 1 2 3 4 5
3. Gathers information from multiple methods and sources. N/A 1 2 3 4 5
4. Is able to administer and score psychological tests N/A 1 2 3 4 5
5. Is able to interpret and integrate psychological test data N/A 1 2 3 4 5
6. Communicates assessment findings in written format N/A 1 2 3 4 5
7 Communicates assessment findings in oral format N/A 1 2 3 4 5
8 Utilizes diagnostic classification systems N/A 1 2 3 4 5
9 Is able to formulate cases from a targeted theoretical framework N/A 1 2 3 4 5
10. Develops a treatment plan consistent with assessment data & case formulation N/A 1 2 3 4 5
Mean
Category Level:
D. Intervention
1. Ability to establish clear, realistic goals with clients N/A 1 2 3 4 5
2. Ability to identify appropriate interventions to meet treatment goals N/A 1 2 3 4 5
3. Ability to implement interventions consistent with case formulation N/A 1 2 3 4 5
4. Ability to manage crises/emergency situations N/A 1 2 3 4 5
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Mean Category Level:
E. Research & Evaluation
1. Demonstrates knowledge of relevant psychological theory, concepts, and research N/A 1 2 3 4 5
2. Demonstrates sound clinical judgment N/A 1 2 3 4 5
3. Demonstrates evidence based approach to clinical work N/A 1 2 3 4 5
Mean Category Level:
F. Supervision/Management
1. Is prepared for supervision N/A 1 2 3 4 5
2. Is open to supervision N/A 1 2 3 4 5
3. Incorporates supervisory feedback into clinical work N/A 1 2 3 4 5
4. Engages in constructive self examination N/A 1 2 3 4 5
5. Is aware of ethical and legal issues in supervision N/A 1 2 3 4 5
6. Understands the organization and role of psychologists in the agency N/A 1 2 3 4 5
7. Is aware of and utilizes appropriate ancillary resources N/A 1 2 3 4 5
Mean
Category Level:
G. Consultation/Education
1. Ability to function in a multi-disciplinary team N/A 1 2 3 4 5
2. Ability to provide consulting interventions N/A 1 2 3 4 5
3. Ability to provide effective training/education to clients N/A 1 2 3 4 5
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Mean Category Level:
H. Professional Behavior/Style
1. Relates well with other staff N/A 1 2 3 4 5
2. Presentation of self (e.g. demeanor, dress) is appropriate and professional N/A 1 2 3 4 5
3. Demonstrates appreciation for local work routine, values, and rules N/A 1 2 3 4 5
4. Keeps appropriate documentation of training activities N/A 1 2 3 4 5
5. Is timely and current with notes and record keeping N/A 1 2 3 4 5
6. Demonstrates awareness of ethical and legal issues in peer and client relationships N/A 1 2 3 4 5
7. Shows progress in developing a professional identity N/A 1 2 3 4 5
Mean Category Level:
Overall Mean Rating
Please add the mean category ratings of sections A
through H above and divide by
8.
Overall Mean Rating =
Comments: should be made based on comparison with other trainees who are at the same level of training. Thank you for general comments as well as specific comments on the trainee’s strengths and areas in need of development.
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Supervisor Signature Date
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Student Signature Date
This evaluation has been shared with me, and any comments that I may have related to this evaluation
shall be found below or on a separate sheet of paper, attached.
Student Comments:
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Return original form to Office of Clinical Training and Psychological Services by the last day of final exams each quarter. Supervisor and Trainee should each keep a copy