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SEACOAST MENTAL HEALTH CENTER, INC. 1145 Sagamore Avenue Portsmouth, N.H. 03801

PSYCHOLOGY INTERN EVALUATION

Intern Name: _____________________

Date of Evaluation: ___________ Evaluation Period: __ Sept-Feb

Number Hours Worked: _______ Total Annual Hours Worked: ______

___ March-Aug ___ Sept-Nov ___ March-May

Primary Supervisor: __________________________ Secondary Supervisor: _________________________ The training program specifies its education and training objectives in terms of core competencies expected of its graduates. Please use the rating scale below to rate the intern’s progress. 5 = Exceptional 4 = Highly Satisfactory 3 = Satisfactory

2 = Minimally Acceptable 1= Unsatisfactory

1.) ____ The intern demonstrates competency in diagnostic intake/assessment through a thorough and integrated written review of the presenting problem, history of the presenting problem, developmental/psychosocial history, medical history, trauma/abuse history, substance abuse history, relevant diversity factors, and formal mental status examination. A psychodynamic formulation occurs in tandem with DSM-IVR diagnostic impressions from which an initial treatment plan is written. Narrative:

2.) ____ The intern demonstrates competency in psychotherapy through the articulation of clear rationale for choice of treatment modality and subsequent interventions; awareness of the interaction of individual diversity factors on symptom presentation, the treatment relationship and the unfolding of treatment; management of ‘frame’and ‘boundary’ issues; evidence of ability to tolerate and


manage affect; awareness of and use of transference and countertransference occurrences; evaluation of the effectiveness of interventions and the expectations that interventions will be modified as necessary; and growth in clinical skill in two or more treatment modalities (individual, couples, group, rapid assessment and crises stabilization). Competency in this area will also include sharing videotaped sessions in supervision and seminars. Narrative:

3.) _____ The intern’s competency in psychodiagnostic testing includes demonstration of the following expectations: a comprehensive interview and medical record review be performed; tests are selected that will answer the referral question; awareness of the validity of each instrument and data interpretation given each test’s reference population; administration follows standardized procedures and when deviations occur they do so with forethought; tests are accurately scored; test data is integrated in a readable and thorough report; recommendations are specific to the patient, practical, and address the referral question; consultation occurs regarding results and recommendations; and all is done with a mindfulness of the APA ethical guidelines for testing. Narrative:

4.) _____ The intern demonstrates competency in supervision as measured by the accumulation of knowledge and understanding of some of the theories of supervision, active engagement in peer supervision, and the ability to engage in conversation about one’s own supervisory experience. Narrative:


5.) _____ The intern exhibits competency in program evaluation through the demonstration of knowledge and understanding of some of the theories and methods of evaluation; routine engagement in the evaluation of services at the departmental level; completion of a group evaluative project; and engagement in informal and formal evaluation of the internship program. Narrative:

6.) _____ The intern demonstrates competency in the area of consultation through the demonstration of knowledge and understanding of the fundamentals of at least one model/theory of consultation; and through engaging in a consulting relationship in which mutually constructed goals are determined and interventions are both made and evaluated. Narrative:

7.) _____The intern engages in the relationship and process of individual supervision and voices curiosity about his/her work in therapy, reflects upon his/her own behavior and its’ impact on patients, learns and practices technical endeavors, examines ethical and professional concerns, and responds favorably to a mixture of support and challenge. The intern identifies his/her learning needs and demonstrates initiative in getting these needs met during the course of the training year. Primary Supervisor Narrative:

Secondary Supervisor Narrative:


8.) _____ The intern demonstrates an ability to relate comfortably and appropriately with each other, other professionals and support staff; to manage interpersonal concerns and conflict respectfully and effectively; and shows respect for and sensitivity toward individual and group diversity. Narrative:

9.) _____ The intern demonstrates his/her identification with the profession of professional psychology through his/her knowledge of the rights, responsibilities, and ethical guidelines of the profession; awareness of current issues affecting the field; ability to conduct his/herself in an ethical manner; and through adherence to organizational policies and procedures. Narrative:

OVERALL PERFORMANCE FOR THE SEMESTER: __________ OVERALL PERFORMANCE FOR THE YEAR: _________ Intern Response (Use reverse side if needed):

Signatures: ___________________________________________ Supervisor Date ___________________________________________ Intern Date


Rating Scale

5 = Exceptional: The intern’s performance was outstanding. 4 = Highly Satisfactory: The intern’s performance exceeded expectations in specific areas; proficiency and skills were clearly above solid competence. 3 = Satisfactory: The intern’s performance was satisfactory with no major problems; expectations were met in all areas. 2 = Minimally Acceptable: The intern’s performance was minimally acceptable; there were some major problems although not severe enough to be considered ‘unsatisfactory’. The following quarter will be considered probationary. A corrective action plan will be initiated. Performance will be evaluated every 3 months to monitor progress. A minimal rating of 2 must be achieved in all competency areas by the end of the training year. 1 = Unsatisfactory: The intern’s performance was characterized as unsatisfactory. A corrective action plan will be initiated. Performance in the 3 months immediately following the unsatisfactory review must be met with a rating of at least a 2. Evaluations will follow at 3 month intervals and a minimal rating of 2 must be maintained. Two consecutive evaluative periods with a rating of 1 constitute grounds for dismissal from the program. Standards to be applied to the rating scale: 1.) If major concern becomes evident in the first month or two of the internship, a three-month evaluation will be held to specifically identify the areas of concern and to develop a corrective action plan. 2.) In order to obtain credit for the internship year, the overall performance rating for the year in all competency areas must be, at a minimum, a 2 - “minimally acceptable”. 3.) If at mid-year any one competency area is rated a 2 - “minimally acceptable”, the overall rating for the semester will be 2 – “minimally acceptable/ probationary status”. The Executive Director, Advisory Board, and the intern’s school will be informed of the areas of concern and the corrective action plan. Significant improvement, as defined in the corrective action plan, will need to occur in order to receive credit for the semester. 4.) If at mid-year any one area is rated 1 – “unsatisfactory”, the overall rating for the semester will be considered “unsatisfactory” and no credit will be given for the semester. The Executive Director, Advisory Board, and the intern’s school will be informed of the intern’s status, and the corrective action plan. Significant improvement, as defined in the corrective action plan, will need to occur in order to receive credit for the second semester of the internship.

2/2010


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Psychology Intern Evaluation