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CASE PRESENTATION EVALUATION FORM-PHD PROGRAM Student’s Name: ____________________________________________________________________ Consultant’s Name: _________________________________________________________________ Committee Member: ________________________________________________________________ Date of Presentation: ________________________________________________________________ For Clinical Practicum Chair only: Date student file reviewed: Dean Approval: _________________ ______________ Signature
Date
Client Information: Initials
Age
Gender
Diagnosis
Treatment Modality
Length of Consultation: _____________________________________________________________ Frequency of Client Contact: ________________________________________________________
Please circle the most appropriate score for each item, relative to the student’s clinical work and the case presentation process. Narrative comment may be added. NOTE: Ratings of “3” represent a student who is performing as would be expected and is on target. Ratings of “4” or above should be reserved for a student who is doing better than expectable or is excelling, while ratings below “3” indicate a need for concern.
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