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Practicum / Internship Manual Updated 8/16/12

Practicum and Internship Student Manual

Master’s in Rehabilitation Counseling

Program

Texas Tech University Health Sciences CenterSchool of Allied Health

Department of Rehabilitation Sciences

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TABLE OF CONTENTS

Rehabilitation Counseling Program Information 6

Manual Overview 7

Practicum Manual 11

Practicum Overview 12

Practicum Clinical Supervision 12

Practicum Clinical Experience 13

Client Contact Hours Documentation 13

Practicum Clinical Site Evaluation Approval Process 14

Practicum Forms 15

Clinical Site Approval Form 16

Practicum Services Agreement Form 18

Clinical Site Orientation Checklist 19

Permission to Videotape/Audiotape Consent Form 20

Clinical Experience Time Log 21

Instructions for Clinical Experience Time Log 22

Internship Manual 24

Internship Overview 25

Internship Clinical Supervision 26

Internship Forms 27

Clinical Site Approval Form 28

Internship Services Agreement Form 30

Clinical Site Orientation Checklist 31

Clinical Experience Time Log 32

Instructions for Clinical Experience Time Log 33

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Evaluation Forms 35

Student Evaluation of the Site and Supervisor 36

Student Evaluation of the Faculty Supervisor 41

Agency Supervisor Evaluation of the Student 44

Student Clinical Self-Evaluation 49

Site Supervisor Evaluation of the Rehabilitation Education Program 53

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Faculty Contact Information

Evans Spears, PhD, CRC

Program Director and Professor

Texas Tech University-Health Sciences Center

Department of Clinic Administration and Rehabilitation Counseling

Room 3B311 3601 4th Street STOP 6225

Lubbock, TX 79430-6225

[email protected]

806-743-4208 (office)

806-743-3244 (fax)

Michelle Aliff, ABD, CRC

Assistant Professor





[email protected]

806-743-3242 (office)

806-743-3244 (fax)

Jacquelyn Dalton, PhD, CRC

Assistant Professor





[email protected]

806-743-3241 (office)

806-743-3244 (fax)

David Schroeder, PhD, CRC

Assistant Professor




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[email protected]

806-743-2592 (office)

806-743-3244 (fax)

Curt Finger

Supervisor of Distance Education Technologies





[email protected]

806-743-4734 (office)

866-240-1182 (toll free)

806-743-3244 (fax)

Nancy Mangum

Unit Coordinator



Room 3B308 3601 4th St. STOP 6225

[email protected]


806-743-2590 (office)

806-743-3244 (fax)

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Rehabilitation Counseling Program Information

The MRC Program faculty, Department of Clinical Administration and Rehabilitation Counseling Chair, and other individuals with an interest in the program worked together to create the Mission statement for the program. The mission of the Texas Tech University Health Sciences Center is:(1) To provide the highest standard of excellence in higher education while pursing

continuous quality improvement; (2) To stimulate the greatest degree of meaningful research; and (3) To support faculty and staff in satisfying those whom we serve.

The mission of the TTUHSC School of Allied Health Sciences (SAHS) is to offer our graduates opportunities to exceed nationally recognized standards of technical competence, while simultaneously developing the professional insight and service-oriented compassion that will enable them to excel in merging “high tech and high touch” throughout their professional careers.

The Vision Statement of the TTUHSC MRC Program: We aspire to be recognized at the national and local levels as a leader in innovative, progressive, comprehensive, and quality rehabilitation education.

The Purpose Statement: The Purpose of the Masters in Rehabilitation Counseling Program is to provide a quality comprehensive rehabilitation counselor education that is progressive in the areas of pedagogy, technology and research, which fosters students’ personal and professional growth and provides leadership in the field at the local and national levels.

A primary component to the fulfillment of the mission, vision, and purpose that guide the rehabilitation counseling education program, is the provision of quality clinical training.

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Manual Overview

The rehabilitation counseling education process consists of two primary components. The first is the didactic instruction received in the core classes of the degree plan, and the second is a clinical educational experience. The clinical education component is divided into two parts, the practicum and the internship. These are two distinct stages of clinical education, and each has unique objectives and educational activities.

We want to emphasize that the clinical experience component of your education should be based on your professional needs, goals, and interests. While there are certain requirements that must be met (i.e. supervision, hours required, etc.), there is a great deal of flexibility for the designing of a meaningful clinical experience. We encourage you to take this opportunity to explore new areas of interest, new skill sets, and new systems of service delivery. Before continuing through this manual, please take a moment to answer the following questions:

1. What do you want to accomplish while engaged in your clinical experience?2. Are there certain populations with whom you are interested in working?3. Do you have specific interests you would like to explore during the clinical

experience?

This personalizing of the practicum and internship is essential to having a meaningful experience. It may be tempting to simply want to complete the experience to fulfill the requirements for graduation. We encourage you to put effort into this component of your education. The amount that you benefit from your clinical education experiences will be directly proportional to the amount of effort you put into it.

All students must complete AHRC 5000 (Pre-Practicum) the semester before beginning Practicum. This non-credit/no cost course will consist of students locating sites, completing Site Affiliation Agreements, and other activities necessary to prepare for Practicum.

Pre-Practicum

All students will be required to participate and complete a 0 credit/0 cost Pre-Practicum course the semester before they start their Practicum experience. This course will provide orientation and preparation for beginning clinical experiences within the program. This course is designed to allow the students to become familiar with all the clinical experience requirements, procedures for documentation, and expectations for practical and professional development throughout the clinical experience. All course objectives must be completed in order to register for the Practicum class.

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The Practicum The Practicum includes coursework and a 100 hour on-site clinical experience, engaging in practicum activities, under the supervision of a certified rehabilitation counselor. Of the required 100 hours, 40 must be direct (client contact) hours completed at a clinical site. In addition to onsite supervision, the student will receive supervision from a faculty member regarding the professional activities in which the student is engaging. Evaluations of the student, onsite supervisor, and internship site are essential components of the Practicum process. The practicum must be successfully completed before continuing on to the internship, except in extenuating circumstances with full faculty approval.

The Internship

The internship is a 600 hour clinical experience, conducting the professional activities of a rehabilitation counselor, under the supervision of a certified rehabilitation counselor. Of the required 600 hours, 240 must be direct (client contact) hours completed at a clinical site. In addition to onsite supervision, the student will receive supervision from a faculty member regarding the professional activities in which the student is engaging. Evaluations of the student, onsite supervisor, and internship site are essential components of the internship process. The internship is graded on a pass / fail basis. Satisfactory completion of the internship is required for graduation.

Clinical Supervision

Clinical supervision for the practicum/internship may occur in three formats, on-site, in class, and individual supervision. On-site supervision will be conducted with the designated site supervisor. In class and individual supervision will take place with the MRC faculty.

On-Site SupervisionOn-site supervision must be conducted on a weekly basis, for at least 1 hour. Supervision is provided by the designated site supervisor. The site supervisor should be a CRC. If this is not the case, then the faculty supervisor can serve as a CRC. Regardless of the status of the site supervisor as a CRC, there must be at least one hour of on-site supervision on a weekly basis. Group SupervisionStudents will participate in group supervision activities within the practicum/internship class. In class supervision may consist of roleplays, case presentations, professional development, and discussion of specific issues that the students are facing in the internship sites.

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Individual SupervisionThere may be additional individual supervision requirements should a faculty member serve as a student’s CRC.

Clinical Sites

During the practicum, clinical sites will be expected to provide students with the following activities:

Clinical Site Orientation (See Orientation Checklist). The site supervisor should be a CRC. If a CRC is unavailable, please contact the

practicum course instructor and a faculty CRC may be assigned. A copy of the site supervisor’s resume and their CRC certificate is required.

Provide meaningful activities (e.g., involvement in cases, on-site training and orientation, supervision, opportunities for growth and development) for the student to engage in during the required 100 hours of clinical experience (40 of which must be direct client contact) for the practicum.

Provide student evaluation as outlined by the Rehabilitation Education Program. Provide evaluation of the rehabilitation education program, and the working

relationship with the agency providing the practicum site. Maintain an open communication with the rehabilitation education program. Provide the following clinical experiences at a minimum:

o The student will have an opportunity to interview and interact with consumers.

o Participate in staffing of consumers.

The final clinical education requirement for the Master’s degree in Rehabilitation Counseling is the Internship. The purpose of the internship is to provide an opportunity for the student to get supervised experience providing rehabilitation counseling services. During the Internship, clinical sites will be expected to provide students with the following activities:

Clinical Site Orientation (See Orientation Checklist). The site supervisor should be a CRC. If a CRC is unavailable, please contact the

practicum course instructor and a faculty CRC may be assigned. A copy of the site supervisor’s resume and their CRC certificate is required.

Provide meaningful activities (e.g., providing rehabilitation counseling services to persons with disabilities) for the student to engage in during the required 600 hours of clinical experience (240 of which must be direct client contact) for the Internship.

Provide student evaluation as outlined by the Rehabilitation Education Program. Provide evaluation of the rehabilitation education program, and the working

relationship with the agency providing the practicum site. Maintain an open communication with the rehabilitation education program. Provide the following clinical experiences at a minimum:

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o The student will have an opportunity to carry a caseload of no less than 3 consumers.

o Students will be provided opportunities to participate in as many clinical services as possible at the internship site.

Technology Requirements

For the provision of clinical supervision in the practicum/internship, students will need to obtain a web conferencing camera, headphones with microphone, as well as necessary software. Information on specific technology is provided on the MRC Portal Site. Web conferencing capabilities will be utilized in group, and at times one-on-one, clinical supervision with the MRC faculty supervisor.

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Practicum Manual

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Practicum Overview

The practicum is a 100 hour educational/clinical experience designed to prepare you for internship. Preparation occurs in three areas: 1) Clinical Skill Development, 2) Administrative Preparation, and 3) Clinical Hours.

Clinical Skill Development

The focus of the practicum includes the development of micro-skills of counseling, development of client focused counseling skills, gaining an understanding of the roles and functions of the rehabilitation counselor, building skills of self-evaluation and introspection, the importance of consultation and supervision, and the development of necessary attitudes for rehabilitation counselors. In addition to these basic skills that are requisite for rehabilitation counseling practice, we will introduce the case conceptualization process.

Practicum Required Activities

Each student will participate in activities that will provide the opportunity for skill development. Skill development will occur by practicing the skills outlined by the course instructor, and participating in course activities as outlined by course syllabi, including weekly online role-plays done via web-conferencing.

Practicum Clinical Supervision

The MRC professor is the instructor for the practicum course. Students will participate in 1 ½ hours of group clinical supervision each week with their practicum instructor and classmates. Supervisory sessions will consist of role plays, evaluation and feedback on counseling skills, discussion of case conceptualization, addressing personal growth and development of personal insight and self-reflection. As clinical supervision is a synchronous activity, students will need to schedule a time to engage in supervision with the practicum instructor. Weekly supervisory sessions are mandatory. Multiple absences may result in failure of the course.

Once the student begins participating in activities within the clinical site, the site supervisor will provide at least one hour of face-to-face supervision each week (this is in addition to the 1 ½ hours of group supervision.)

Physical Oversight/Supervision

Any student who is at a practicum site where 33% of their work is without physical oversight, meaning their supervisor is physically located in the same office, must adhere to the following additional requirements:

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1. Students will be required to video or audio tape three sessions with a client (one at the beginning, one at the middle and one at the end) to be reviewed and evaluated by the faculty supervisor.

2. The middle tape will be evaluated by the site supervisor.3. A weekly log of activities must be turned in to the faculty supervisor every

week during the duration of the clinical.4. Faculty must have a meeting with the site supervisor prior to site approval to

explain the additional requirements.

If a student is working at a business they own, they will have to also hire an outside supervisor who has a Master level degree in counseling or closely related field and have current certification and/or licensure.

Ongoing EvaluationPeriodic written reviews of the student’s progress occur throughout the semester. There will be a mandatory midterm progress review. Then following the mid-term review the student will receive a written appraisal of the student’s progress from the professor.

FeesThe TTUHSC School of Allied Health Sciences requires a $50 graduation fee for students planning to graduate. As the practicum initiates the final phase of the degree program, the graduation fee will be assessed to students entering the practicum course.

Practicum Clinical Experience

Each student is required to spend at least 40 hours (out of 100) in direct client contact. The purpose of the clinical experience in the practicum is to provide an opportunity for the student to get oriented to the clinical site, to observe the range of rehabilitation counseling services provided in agency settings, to begin to exercise clinical reasoning and intervention skills, and receive an introduction to the workings of a rehabilitation agency. Observation may be used for a portion of direct client contact hours with the amount of hours counted to be determined in consultation with your faculty supervisor.

Client Contact Hours Documentation:

Students should use the following codes to document their on-site activities:

DC (Direct Client Contact)- Time spent personally counseling or advising clients, testing or evaluating the client, interviewing, job development, “staffing” or group problem solving / planning with other rehabilitation professionals, transferability of skills analysis, performing a job analysis for the specific consumer, or any other service done directly with the client. Essentially, if the consumer is present count it as a contact hour.

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CE (Clinical Experience)- Time spent in orientation, time on paperwork, file review, filing, and time spent in learning and performing administrative procedures.

CS (Clinical Supervision)- Time spent in supervision with site supervisor or faculty supervisor and time spent in weekly group supervision meeting.

IP (Interprofessional Activities)- Time spent interacting with professionals outside of the rehabilitation field for the client.

*Instructions for documentations can be found with the form on page 21.*

Practicum Clinical Site Evaluation Approval Process

Speak to Advisor Clinical Site Approval Form Practicum Services Agreement Form Affiliation Agreement

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Practicum Forms

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Clinical Site Approval Form

Each student must fill out this form in evaluation of the clinical site they intend to use for practicum and internship.

Student Name: ___________________________ Date: _______________________

Legal Agency Name: ______________________________________________________

Agency Address: _________________________________________________________

Designated Site Supervisor: _________________________________________________

Site Supervisor Phone: ________________________ Email: ______________________

Site Supervisor CRC #:_________________________Fax:_____________________

If a different person will be responsible for signing contractual agreements with the University, please attach the authorized signee's name, address, phone, fax, and email address as well.

This clinical site will be used for:

Practicum Internship Both

Type of Facility: State Agency Non-Profit Service

Provider

Private Rehabilitation Other:____________________________

Client Age Range: (Check All That Apply) 0 – 10 years 10 – 21 years 21 – 40 years

40 – 60 years 60 and over

Disability: (Check All That Apply) Persons with Mental Illness Persons with Mental

Retardation Persons with Learning

Disabilities Persons with Deafness /

Hearing Impaired

Persons with Physical Disabilities Persons with Traumatic Brain Injury Other:________________________

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Populations: (Check All That Apply) Alcohol / Substance Abuse AT Risk Youth Brain Injury / Stroke Deaf / Hard of Hearing Developmental Disabilities Geriatric HIV/AIDS

Homeless Industrial Injuries Learning Disabilities Multiple Disabilities Psychiatric Spinal Cord Injuries Visual Disability Other:_______________________

Student Prerequisites: (If Applicable) Car Required Certificate for Blood-Borne

Pathogen Criminal Background Check CPR Interview

Pediatric CPR Physical Examination Universal Precautions Training Other:______________________

Job Description: (Please attach on a separate sheet)

Note: Parts of this form were adapted from the Boston University Rehabilitation Counseling Internship and Practicum Manual

Please send completed form to your faculty supervisor (please write your faculty supervisors name):

Faculty Advisor Master’s of Rehabilitation Counseling ProgramTexas Tech University Health Sciences CenterSchool of Allied Health Sciences3601 4th St. STOP 6225Lubbock, TX 79430Fax: 806-743-3244

Advisor Approval: __________________________________Y/N

Semester Start Date: Fall Spring Summer

Early Start Date: Y/N Date Starting: ______________

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Practicum Services Agreement Form

Intern Name:___________________________________________________________

Internship Agency: ______________________________________________________

Internship Agency Address:________________________________________________

Site Supervisor:______________________ Site Supervisor’s CRC #:_____________

Phone:________________________ Email:__________________________

Faculty Advisor:_____________________

Please check the clinical services in which the intern will have an opportunity to participate:

Vocational Counseling Administering Assessments

Case Management Program Evaluation

Job Placement and Development

Documentation and Case Record Maintenance.

Rehabilitation Plan Development

Staff Meetings

Intake Interviewing Employer Networking

Counseling (Other than Vocationally Oriented)

Life Care Plan Development

Worker’s Compensation Case Work

Forensic Research

Social Security Case Work

As a practicum student, __________________________ (Student Name) will have involvement in at least three (3) cases, to be conducted under the direct supervision of the assigned site supervisor.

___________________________________________ _______________Site Supervisor Signature DateMail completed to:

Faculty Supervisor (insert faculty supervisors name here)Masters of Rehabilitation Counseling ProgramTexas Tech University Health Sciences CenterSchool of Allied Health Sciences3601 4th St STOP 6225Lubbock, TX 79430-6225

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Clinical Site Orientation Checklist

The following are orientation activities that need to occur at the beginning of the internship experience, with the site supervisor and the intern. Please indicate the date that each activity was completed. Be sure that the form contains all necessary signatures prior to turning it in. Forms not containing the necessary signatures will not be accepted.

Activity Date Completed

1. Orientation to agency services that are provided.* _____________

2. Explanation and review of agency policies and procedures.* _____________

3. Introduction to agency staff and personnel, and explanation of their roles and functions within the agency.* _____________

4. Observe all aspects of service delivery within the agency.* _____________

5. Review of confidentiality procedures.* _____________

6. Review of the CRC Code of Ethics.* _____________

7. Review of site expectations for employee/student conduct (e.g. attendance, dress code, etc.). _____________

8. Review of site expectations for employee/student duties/professional responsibilities

_____________

9. Completion of the appropriate Services Agreement Form. _____________* Note: If the items with an asterisk were conducted as part of the practicum, and if the practicum and internship sites are the same, then put the word “Practicum” in the Date Completed Column.

We affirm that these orientation activities were completed, and that all questions by both parties were addressed.

Student Name Date Site Supervisor Name Date

Mail completed forms to:


Permission to Videotape/Audiotape Consent Form

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The process of videotaping/audio taping counseling sessions plays a large role in the education of rehabilitation counselors. Such tapes assist in the evaluation process for student counselors. Additionally, the rights of participants are of utmost importance in this process. The following are program guidelines that the student counselor will follow to ensure the participant’s confidentiality.

1. Before videotaping/audio taping any participant, a signed release of confidentiality form must be signed and filed in the clinical chart, as well as with the MRC Faculty Supervisor.

2. All recordings will be kept in a secure environment.3. All recordings will be erased or destroyed at the conclusion of the practicum or

internship.4. Videotapes/Audiotapes will be viewed by a course supervisor, and other students.

All reviewers of the material will be expected to maintain confidentiality about the material they see or hear.

5. Even if a consent form has been signed, participants have the option to stop or deny taping at any time.

6. Any concerns regarding this process or about consent of videotaping/audio taping activities may be addressed with the MRC Program Director at 1-806-743-4208.

I understand the information above, and give permission for ____________________ (Student Counselor Name) to make video/audio recordings of my clinical sessions.

Client Date Student Counselor Name Date

Please note this form may or may not be utilized by your faculty supervisor.

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Clinical Experience Time LogMaster’s of Rehabilitation Counseling – Texas Tech University Health Sciences Center

Please fax bi-weekly to: 806.743.3244

Box 1:Student Name Box 2: Faculty Supervisor

Each Student will need to log at the required number of hours for the experience (100 for Practicum, 600 for Internship). For all experiences 40% of time is expected to be in direct client contact. Use this sheet to record the time you spend in your clinical activities. Indicate by date the amount of time spent in each of the activities. You should complete a form every two weeks and submit following the guidelines created by your faculty supervisor. ALL forms must have a signature of BOTH the Student and Site Supervisor for consideration. Unsigned forms will not be counted. Please retain copies for your records.

WEEKLY REPORTING – Table 1Date Supervision Direct

Client Service

Clinical Experience

Inter-professional

Daily Total

Box A Box B Box C Box D Box E Box FBox A Box B Box C Box D Box E Box FBox A Box B Box C Box D Box E Box FBox A Box B Box C Box D Box E Box FBox A Box B Box C Box D Box E Box FWEEK ONETOTAL

Box B1 Box C2 Box D2 Box E2 Box F2

EXPERIENCE SUMMARY REPORTS – Table 4Date Supervision Direct Indirect Transit TotalThis Period Box B1 Box C1 Box D1 Box E1 Box F1Last B-F3’s Box B2 Box C2 Box D2 Box E2 Box E2Experience To Date


By signing below, I am certifying the information on this form to be true.

Box 3: Student Signature Box 4: Site Supervisor Signature

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Instructions for Clinical Experience Time Log

CRITICAL ITEMS:

1. Time logs are due by 5:00 pm CST on the Friday following the time period of the log. They may be scanned as a PDF or DOC file and emailed to the instructor or faxed to 806.743.3244.

2. All forms must be complete, with no blank data spaces. If no hours accrued, fill the space with a zero.

3. All forms must be signed by the student and site supervisor.4. Students accruing zero hours in a reporting period are required to contact their

assigned faculty supervisor to provide justification.5. NO HOURS may be counted until the Agency Agreement has either been

completed. IT IS THE STUDENT’S RESPONSIBILITY TO INSURE COMPLETION.

6. THE STUDENT is responsible for reporting their experience hours. Points will only be available for time logs submitted timely. Late cards may be accepted, but not likely following the deadline for the following period. Time logs not submitted in accordance with these guidelines may not be counted towards completion of the program requirements

BOX by BOX Instructions

Table 1:

Box 1: Student name (as registered) typewritten or legibly printedBox 2: Faculty Supervisor Name typewritten or legibly printedBox A: The date of the experience activity (date worked) in mm/dd/yyyy form.Box B: Supervision activities. Includes site supervision and faculty group

supervision.Box C: Direct service hours – only hours directly linked to service of 1 individual

client.Box D: Ancillary contacts regarding a client, family or situation; generalized

rehabilitation duties.Box E: Travel time when client is not present.Box F: Total of daily activities (add boxes B, C, D, E). Note: Cannot total more

than 10 hours without prior approval.

Box B1: Total of all column B activities for week.Box C1: Total of all column C activities for week.Box D1: Total of all column D activities for week.Box E1: Total of all column E activities for weekBox F1: Total of all column F activities for week. Note: F1 or F2 cannot total

more than 42 hours without prior approval.

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Table 2 - Experience Summary Reports

Box B1 Copy B1 from Table 1Box C1 Copy C1 from Table 1Box D1 Copy D1 from Table 1Box E1 Copy E1 from Table 1Box F1Copy F1 from Table 1Box B2 Copy last reporting period’s B3Box C2 Copy last reporting period’s C3Box D2 Copy last reporting period’s D3Box E2 Copy last reporting period’s E3Box F2Copy last reporting period’s F3Box B3 Add box B1 and B2Box C3 Add box C1 and C2Box D3 Add box D1 and D2Box E3 Add box E1 and E2Box F3Add box F1 and F2

Box 3: Student signature (in ink) and date.

Box 4: Site Supervisor signature (in ink) and date.

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Internship Manual

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Internship Overview

The final clinical education requirement for the Master’s degree in Rehabilitation Counseling is the Internship. The purpose of the internship is to provide an opportunity for the student to get supervised experience providing rehabilitation counseling services. It consists of a 600 hour supervised clinical experience, providing rehabilitation counseling services to persons with disabilities, onsite clinical supervision. A total of 240 of the 600 hours must be direct consumer/client contact hours. Course activities will include continued peer review, group supervision, and assignments.

Clinical Skill DevelopmentThe continued development of clinical skills is the primary focus of the internship experience. Students will be expected to continue to address competency with the site supervisor, as well as address continued skill development in the internship class. Internship activities that may facilitate continued clinical skill development may include videotaping counseling sessions, case review, case conceptualization, and other activities as determined by the clinical supervisor.

Case AssignmentsEach student will be assigned, by site supervisor, primary responsibility for specific cases. While the total number of cases assigned to the student is up to the discretion of the site supervisor, the total number should not be less than three. In addition, interns should have an opportunity to participate in as many clinical services as are offered at the internship site. This should be planned with the site supervisor.

Staff and Team ParticipationStudents will participate in the staff and rehabilitation team meetings that may occur in the clinical site. They should be given an opportunity to report on their specific cases, when appropriate, and be actively involved in the clinical discourse. Opportunities for asking questions and gathering additional information should be provided.

Joining a National Professional Organization - Students are encouraged to join a professional organization, but it is not required. Professional organization membership is an important part of the process for professional identity development. It assists in the process of gaining additional skills and knowledge through continuing education, and staying current in the field. It facilitates the socialization process, and provides new professionals the opportunity to engage the profession at a national level. Most organizations have a reasonable student rate for membership. Students are encouraged to join a national rehabilitation counseling professional organization. Many professional organizations also provide additional liability insurance at discounted rates for students.

Internship Clinical Site Approval Process Contact your advisor Clinical Site Approval Form Internship Services Agreement Form Clinical Site Orientation Checklist

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Internship Clinical Supervision

Physical Oversight/Supervision

Any student who has more than 33% of their clinical time without physical oversight must adhere to the following additional requirements:

1. Extra supervision from site supervisor-students need an average ½ hour of supervision from their site supervisor for every 10 hrs/week working in the clinical. Minimum amount per week is 1 hour.

2. A weekly log of their activities must be turned into the faculty supervisor every week for the duration of the clinical.

3. Faculty must have a meeting with the site supervisor prior to site approval to explain the additional requirements.

If a student is working at a business they own, they will have to also hire an outside supervisor who has a Master level degree in counseling or closely related field and have current certification and/or licensure.

Ongoing EvaluationPeriodic reviews of the student’s progress occur throughout the semester. There will be a mandatory midterm progress review. Then following the mid-term review the student will receive a written appraisal of the student’s progress from the professor.

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Internship Forms

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Clinical Site Approval Form

Each student must fill out this form in evaluation of the clinical site they intend to use for practicum and internship.

Student Name: ___________________________ Date: _______________________

Agency Name: __________________________________________________________

Agency Address: _________________________________________________________

Designated Site Supervisor: _________________________________________________

Site Supervisor Phone: ________________________ Email: ______________________

Site Supervisor CRC #:_________________________Fax:_____________________

This clinical site will be used for:

Practicum Internship Both

Type of Facility: State Agency Non-Profit Service

Provider

Private Rehabilitation Other:____________________________

Client Age Range: (Check All That Apply) 0 – 10 years 10 – 21 years 21 – 40 years

40 – 60 years 60 and over

Disability: (Check All That Apply) Persons with Mental Illness Persons with Mental

Retardation Persons with Learning

Disabilities Persons with Deafness /

Hearing Impaired

Persons with Physical Disabilities Persons with Traumatic Brain Injury Other:________________________

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Populations: (Check All That Apply) Alcohol / Substance Abuse AT Risk Youth Brain Injury / Stroke Deaf / Hard of Hearing Developmental Disabilities Geriatric HIV/AIDS

Homeless Industrial Injuries Learning Disabilities Multiple Disabilities Psychiatric Spinal Cord Injuries Visual Disability Other:_______________________

Student Prerequisites: (If Applicable) Car Required Certificate for Blood-Borne

Pathogen Criminal Background Check CPR Interview

Pediatric CPR Physical Examination Universal Precautions Training Other:______________________

Job Description: (Please attach on a separate sheet)

Note: Parts of this form were adapted from the Boston University Rehabilitation Counseling Internship and Practicum Manual

Please send completed form to your faculty supervisor (please write your faculty supervisors name):

Faculty Advisor Master’s of Rehabilitation Counseling ProgramTexas Tech University Health Sciences CenterSchool of Allied Health Sciences3601 4th St. STOP 6225Lubbock, TX 79430Fax: 806-743-3244

Internship Services Agreement Form

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Intern Name:___________________________________________________________

Internship Agency: ______________________________________________________

Internship Agency Address:________________________________________________

Site Supervisor:______________________ Site Supervisor’s CRC #:_____________

Phone:________________________ Email:__________________________

Faculty Advisor:_____________________

Please check the clinical services in which the intern will have an opportunity to participate:

Vocational Counseling Administering Assessments

Case Management Program Evaluation

Job Placement and Development

Documentation and Case Record Maintenance.

Rehabilitation Plan Development

Staff Meetings

Intake Interviewing Employer Networking

Counseling (Other than Vocationally Oriented)

Life Care Plan Development

Worker’s Compensation Case Work

Forensic Research

Social Security Case Work

As an intern, __________________________ (Student Name) will be assigned at responsibility for at least three (3) cases, to be conducted under the direct supervision of the assigned site supervisor.

___________________________________________ _______________Site Supervisor Signature Date

Mail completed form to:Faculty Supervisor (insert faculty supervisors name here)Masters of Rehabilitation Counseling ProgramTexas Tech University Health Sciences CenterSchool of Allied Health Sciences3601 4th St STOP 6225Lubbock, TX 79430-6225

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Clinical Site Orientation Checklist

The following are orientation activities that need to occur at the beginning of the internship experience, with the site supervisor and the intern. Please indicate the date that each activity was completed. Be sure that the form contains all necessary signatures prior to turning it in. Forms not containing the necessary signatures will not be accepted.

Activity Date Completed

10. Orientation to agency services that are provided.* _____________

11. Explanation and review of agency policies and procedures.* _____________

12. Introduction to agency staff and personnel, and explanation of their roles and functions within the agency.* _____________

13. Observe all aspects of service delivery within the agency.* _____________

14. Review of confidentiality procedures.* _____________

15. Review of the CRC Code of Ethics.* _____________

16. Review of site expectations for employee/student conduct (e.g. attendance, dress code, etc.). _____________

17. Review of site expectations for employee/student duties/professional responsibilities

_____________

18. Completion of the appropriate Services Agreement Form. _____________* Note: If the items with an asterisk were conducted as part of the practicum, and if the practicum and internship sites are the same, then put the word “Practicum” in the Date Completed Column.

We affirm that these orientation activities were completed, and that all questions by both parties were addressed.

Intern Name Date Site Supervisor Name Date

Mail completed forms to:


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Clinical Experience Time LogMaster’s of Rehabilitation Counseling – Texas Tech University Health Sciences Center

Please fax bi-weekly to: 806.743.3244

Box 1:Student Name Box 2: Faculty Supervisor

Each Student will need to log at the required number of hours for the experience (100 for Practicum, 600 for Internship). For all experiences 40% of time is expected to be in direct client contact. Use this sheet to record the time you spend in your clinical activities. Indicate by date the amount of time spent in each of the activities. You should complete a form every two weeks and submit following the guidelines created by your faculty supervisor. ALL forms must have a signature of BOTH the Student and Site Supervisor for consideration. Unsigned forms will not be counted. Please retain copies for your records.

WEEKLY REPORTING – Table 1Date Supervision Direct

Client Service

Clinical Experience

Inter-professional

Daily Total

Box A Box B Box C Box D Box E Box FBox A Box B Box C Box D Box E Box FBox A Box B Box C Box D Box E Box FBox A Box B Box C Box D Box E Box FBox A Box B Box C Box D Box E Box FWEEK ONETOTAL


EXPERIENCE SUMMARY REPORTS – Table 4Date Supervision Direct Indirect Transit TotalThis Period Box B1 Box C1 Box D1 Box E1 Box F1Last B-F3’s Box B2 Box C2 Box D2 Box E2 Box E2Experience To Date


By signing below, I am certifying the information on this form to be true.

Box 3: Student Signature Box 4: Site Supervisor Signature

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Instructions for Clinical Experience Time Log

CRITICAL ITEMS:

1. Time logs are due by 5:00 pm CST on the Friday following the time period of the log. They may be scanned as a PDF or DOC file and emailed to the instructor or faxed to 806.743.3244.

2. All forms must be complete, with no blank data spaces. If no hours accrued, fill the space with a zero.

3. All forms must be signed by the student and site supervisor.4. Students accruing zero hours in a reporting period are required to contact their

assigned faculty supervisor to provide justification.5. NO HOURS may be counted until the Agency Agreement has either been

completed. IT IS THE STUDENT’S RESPONSIBILITY TO INSURE COMPLETION.

6. THE STUDENT is responsible for reporting their experience hours. Points will only be available for time logs submitted timely. Late cards may be accepted, but not likely following the deadline for the following period. Time logs not submitted in accordance with these guidelines may not be counted towards completion of the program requirements

BOX by BOX Instructions

Table 1:

Box 1: Student name (as registered) typewritten or legibly printedBox 2: Faculty Supervisor Name typewritten or legibly printedBox A: The date of the experience activity (date worked) in mm/dd/yyyy form.Box B: Supervision activities. Includes site supervision and faculty group

supervision.Box C: Direct service hours – only hours directly linked to service of 1 individual

client.Box D: Ancillary contacts regarding a client, family or situation; generalized

rehabilitation duties.Box E: Travel time when client is not present.Box F: Total of daily activities (add boxes B, C, D, E). Note: Cannot total more

than 10 hours without prior approval.

Box B1: Total of all column B activities for week.Box C1: Total of all column C activities for week.Box D1: Total of all column D activities for week.Box E1: Total of all column E activities for weekBox F1: Total of all column F activities for week. Note: F1 or F2 cannot total

more than 42 hours without prior approval.

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Table 2 - Experience Summary Reports

Box B1 Copy B1 from Table 1Box C1 Copy C1 from Table 1Box D1 Copy D1 from Table 1Box E1 Copy E1 from Table 1Box F1Copy F1 from Table 1Box B2 Copy last reporting period’s B3Box C2 Copy last reporting period’s C3Box D2 Copy last reporting period’s D3Box E2 Copy last reporting period’s E3Box F2Copy last reporting period’s F3Box B3 Add box B1 and B2Box C3 Add box C1 and C2Box D3 Add box D1 and D2Box E3 Add box E1 and E2Box F3Add box F1 and F2

Box 3: Student signature (in ink) and date.

Box 4: Site Supervisor signature (in ink) and date.

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Evaluation FormsRequired for Both Practicum & Internship

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STUDENT EVALUATION OF THE SITE AND SUPERVISOR

TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTERRehabilitation Counseling Program

Student:______________________________________________________________

Site Supervisor:________________________________________________________

Agency:_______________________________________________________________

Semester:_________________________ Date:________________________________

Directions: This questionnaire is in two parts: The first part is open-ended; the second part is a rating scale called the Supervisory Working Alliance Inventory (Efstation, Patton, & Kardash, 1990). Complete both parts and send or fax to:


Fax: 806-743-3244

NOTE: Copies of this information is not provided to the internship site, unless by previous agreement.

What was the best part of being at this agency?

36


Approximately how many consumers were you actively involved with each week?

__________________________________________________________________

How many weeks after beginning your practicum/internship did you meet with your first consumer?

_______________________________

What skill areas were addressed most / least effectively in your practicum/internship?

How was your clinical practicum/internship consistent with your future goals and relevant to increasing your knowledge of the rehabilitation field?

What changes would improve this practicum/internship site?

37


Your weekly supervision consisted mainly of the following: (Check All That Apply)

One-to-one Videotape Supervision Group Videotape Supervision Discussion of Case Reports

Discussion of Client Services Other:___________________

Please check the appropriate response to each statement:

Supervisory sessions were held regularly each week.

Agree Disagree

My supervisor was readily available for my supervisory sessions.

Agree Disagree

I would recommend this supervisor to another student beginning the internship.

Agree Disagree

I would recommend this agency to another student beginning the internship.

Agree Disagree

Note: The first half of this evaluation form was adapted from the Boston University Rehabilitation Counseling Practicum and Internship Manual.

THE SUPERVISORY WORKING ALLIANCE INVENTORY-TRAINEE FORM

Circle the appropriate rating for your interaction with your supervisor.

Almost AlmostNever Always

1. I feel comfortable working with my supervisor.

1 2 3 4 5 6 7

2. My supervisor welcomes my explanations about the client’s behavior

1 2 3 4 5 6 7

3. My supervisor makes the effort to understand me.

1 2 3 4 5 6 7

Almost Almost

38


Never Always

4. My supervisor encourages me to talk about my work with clients in ways that are comfortable for me.

5. My supervisor is tactful when commenting about my performance.

6. My supervisor encourages me to formulate my own interventions with the client.

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

7. My supervisor helps me talk freely in our sessions.

1 2 3 4 5 6 7

8. My supervisor stays in tune with me during supervision.

1 2 3 4 5 6 7

9. I understand client behavior and treatment techniques similar to the way my supervisor does.

1 2 3 4 5 6 7

10. I feel free to mention to my supervisor any troublesome feeling I might have about him/her.

1 2 3 4 5 6 7

11. My supervisor treats me like a colleague in our supervisory sessions.

1 2 3 4 5 6 7

12. In supervision, I am more curious thananxious when discussing my difficulties with clients.

1 2 3 4 5 6 7

13. In supervision, my supervisor places a high priority on our understanding the client’s perspective.

1 2 3 4 5 6 7

14. My supervisor encourages me to take time to understand what the client is saying and doing.

1 2 3 4 5 6 7

39


Almost Almost Never Always

15. My supervisor’s style is to carefully and systematically consider the material I bring to supervision.

1 2 3 4 5 6 7

16. When correcting my errors with a client, my supervisor offers alternative ways of intervening with that client.

1 2 3 4 5 6 7

17. My supervisor helps me work within a specific treatment plan with my clients.

1 2 3 4 5 6 7

18. My supervisor helps me stay on track during our meetings.

1 2 3 4 5 6 7

19. I work with my supervisor on specific goals in the supervisory session.

1 2 3 4 5 6 7

40


STUDENT EVALUATION OF THE FACULTY SUPERVISOR


Directions: Please provide evaluation of your MRC faculty supervisor by completing the following form. Complete the form by checking the appropriate box, or number for each item. The evaluation of your faculty supervisor will not have any impact on your grade. Send or fax the completed evaluation to:

Faculty Supervisor (insert faculty supervisors name here)Master’s of Rehabilitation Counseling ProgramTexas Tech University Health Sciences CenterSchool of Allied Health Sciences3601 4th St. STOP 6225Lubbock, TX 79430-6225Fax: 806-743-3244

Please check the appropriate response to each statement:

Supervisory sessions were held regularly each week.

Agree Disagree

My supervisor was readily available for my supervisory sessions.

Agree Disagree

I would recommend this supervisor to another student beginning the internship.

Agree Disagree

Note: The first half of this evaluation form was adapted from the Boston University Rehabilitation Counseling Practicum and Internship Manual.

41


THE SUPERVISORY WORKING ALLIANCE INVENTORY-TRAINEE FORM

Circle the appropriate rating for your interaction with your supervisor.

Almost AlmostNever Always

I feel comfortable working with my supervisor.

1 2 3 4 5 6 7

My supervisor welcomes my explanations about the client’s behavior

1 2 3 4 5 6 7

My supervisor makes the effort to understand me.

1 2 3 4 5 6 7

My supervisor encourages me to talk about my work with clients in ways that are comfortable for me.

1 2 3 4 5 6 7

My supervisor is tactful when commenting about my performance.

1 2 3 4 5 6 7

My supervisor encourages me to formulate my own interventions with the client.

1 2 3 4 5 6 7

My supervisor helps me talk freely in our sessions.

1 2 3 4 5 6 7

My supervisor stays in tune with me during supervision.

1 2 3 4 5 6 7

I understand client behavior and treatment techniques similar to the way my supervisor does.

1 2 3 4 5 6 7

I feel free to mention to my supervisor any troublesome feeling I might have about him/her.

1 2 3 4 5 6 7

My supervisor treats me like a colleague in our supervisory sessions.

1 2 3 4 5 6 7

In supervision, I am more curious thananxious when discussing my difficulties with clients.

1 2 3 4 5 6 7

42


In supervision, my supervisor places a high priority on our understanding the client’s perspective.

1 2 3 4 5 6 7

My supervisor encourages me to take time to understand what the client is saying and doing.

1 2 3 4 5 6 7

My supervisor’s style is to carefully and systematically consider the material I bring to supervision.

1 2 3 4 5 6 7

Almost Almost Never Always

When correcting my errors with a client, my supervisor offers alternative ways of intervening with that client.

1 2 3 4 5 6 7

My supervisor helps me work within a specific treatment plan with my clients.

1 2 3 4 5 6 7

My supervisor helps me stay on track during our meetings.

1 2 3 4 5 6 7

I work with my supervisor on specific goals in the supervisory session.

1 2 3 4 5 6 7

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AGENCY SUPERVISOR EVALUATION OF THE STUDENT


Student ________________________________________________________________

Supervisor ______________________________________________________________

Agency _________________________________________________________________

Semester __________________________ Date _______________________________

Directions: This questionnaire is in two parts: the first part is open-ended; the second part is a rating scale. Complete both parts, adding any comments you wish. This evaluation should be discussed with the student prior to its submission to the University.

1. StrengthsList those duties and/or functions which the internship student has performed well and which have contributed to the overall attainment of the practicum/internship objectives. Be specific.

2. Areas for ImprovementList those duties and/or functions in which the student could improve his/her practicum/internship performance. Be specific.

3. The student’s development seems to be progressing at a rate which is (circle one):

SATISFACTORY PLUS SATISFACTORY SATISFACTORY MINUS UNSATISFACTORY (explain)

44


4. Describe this student’s potential to become an effective rehabilitation counselor, given appropriate supervision and training.

5. What are your recommendations for the University to consider in reviewing and planning the ongoing clinical training program for this and other rehabilitation counseling trainees?

6. Additional comments:

\Listed below are the outcome criteria/standards which faculty emphasize in individual supervision of rehabilitation counselor trainees. Underlying these criteria is the assumption that our overall goal is educating students to become effective counselors. Please read each of the phrases below and circle the most appropriate numbers. Where applicable, give examples of student’s performance in each area.

5 – Exceptional in almost all respects of outstanding promise4 – Acceptable in all aspects, exceptional in some3 – Acceptable in all or almost all respects, of good general promise2 – Acceptable in most respects, unacceptable in some1 – Unacceptable in many respects, of poor promiseN – Not enough information to rate, or not applicable to placement

45


I. HELPING SKILLS

A. Engaging the client in the counseling process 1 2 3 4 5 Nthrough attending and orienting.

B. Gathering pertinent information from the client 1 2 3 4 5 Nand relevant other through assessments, observa-tions, and use of facilitative questions.

C. Demonstrating understanding of the client’s ideas, 1 2 3 4 5 Nexperiences, and beliefs through reflection offeelings and meanings of client statements.

D. Self-disclosing in a way that facilitates formation 1 2 3 4 5 Nof an effective counseling relationship and servesto further client exploration.

E. Limit setting, confrontation, and disagreeing as 1 2 3 4 5 Nneeded, while maintaining a respectful andsupportive attitude towards the client.

F. Assessing client traits, problems, and needs in a 1 2 3 4 5 Ncomprehensive and specific manner thatemphasizes strengths and deficits in behavioralterms.

G. Goal setting that reflects the client’s perspective 1 2 3 4 5 Non wants and needs.

H. Planning for interventions and services that will 1 2 3 4 5 Nassist the client in achieving his or her goals.

I. Intervening in ways that produce client progress 1 2 3 4 5 Nin achieving his or her behavioral and/or emotionalgoals.

J. Summarizing process dynamics, themes, activities, 1 2 3 4 5 Nand milestones in the counseling relationship.

K. Evaluating progress with the client on an ongoing 1 2 3 4 5 Nbasis as well as at points of termination or otherchanges in the counseling relationship.

46


II. PROFESSIONAL ISSUES

A. Use of supervision, including preparation, 1 2 3 4 5 Nparticipation, and follow through.

B. Preparation of written reports, progress notes, 1 2 3 4 5 Nand correspondence, emphasizing clarity,organization, and professional presentation.

C. Understanding of ethical issues, including, for 1 2 3 4 5 Nexample, confidentiality, representation ofcompetence and qualifications, loyalties, andinformed consent.

D. Identified personal values and beliefs that may 1 2 3 4 5 Nimpact on ability to fill the role of rehabilitationcounselor.

E. Engages in self exploration. 1 2 3 4 5 N

F. Recognizes personally sensitive areas in counseling 1 2 3 4 5 Ncontent and/or process.

G. Controls and explores own feelings and personal 1 2 3 4 5 Nthoughts about clients to increase understandingand to decrease interference in the counselorrelationship.

H. Requests guidance as needed while demonstrating 1 2 3 4 5 Nan openness to experimentation and risk taking.

I. Evaluates relevance, value, and meaning of feed- 1 2 3 4 5 Nback and implements changes as needed.

J. Sets career goals. 1 2 3 4 5 N

47


III. SELF AWARENESS

A. Sets personal learning goals 1 2 3 4 5 N

B. Evaluates progress towards personal goals. 1 2 3 4 5 N

C. Gives an accurate and balanced self-assessment 1 2 3 4 5 Nof professional competencies.

Circle your overall rating for this student for his/her internship experience.


1 2 3 4 5 N

Signed: ___________________________________ Agency Supervisor

Mail and fax to:

Faculty Supervisor (insert faculty supervisors name here)Masters of Rehabilitation Counseling ProgramTexas Tech University Health Sciences CenterSchool of Allied Health Sciences3601 4th St STOP 6225Lubbock, TX 79430

FAX: 806-743-3244

Note: This evaluation has been adapted from the Boston University Rehabilitation Counseling Practicum and Internship Manual

48


STUDENT CLINICAL SELF-EVALUATION


Student ________________________________________________________________

Supervisor ______________________________________________________________

Agency _________________________________________________________________

Semester __________________________ Date _______________________________

Directions: This questionnaire is in two parts: the first part is open-ended; the second part is a rating scale. Complete both parts, adding any comments you wish. This evaluation should be discussed with the student prior to its submission to the University.

Listed below are 1. Strengths

List those duties and/or functions which you feel you have performed well, and which have contributed to the overall attainment of the internship objectives. Be specific.

2. Areas for ImprovementList those duties and/or functions in which you feel you could improve your internship performance. Be specific.

49


3. You feel your development seems to be progressing at a rate which is (check one):

Unsatisfactory Excellent

_______1 ______2 ______3 _____4 _______5

Listed below are the outcome criteria/standards which faculty emphasize in individual supervision of rehabilitation counselor trainees. Underlying these criteria is the assumption that our overall goal is educating students to become effective counselors. Please read each of the phrases below and circle the most appropriate numbers. Where applicable, give examples of your performance in each area.


III. HELPING SKILLS

A. Engaging the client in the counseling process 1 2 3 4 5 Nthrough attending and orienting.

B. Gathering pertinent information from the client 1 2 3 4 5 Nand relevant other through assessments, observa-tions, and use of facilitative questions.

C. Demonstrating understanding of the client’s ideas, 1 2 3 4 5 Nexperiences, and beliefs through reflection offeelings and meanings of client statements.

D. Self-disclosing in a way that facilitates formation 1 2 3 4 5 Nof an effective counseling relationship and servesto further client exploration.

E. Limit setting, confrontation, and disagreeing as 1 2 3 4 5 Nneeded, while maintaining a respectful andsupportive attitude towards the client.

F. Assessing client traits, problems, and needs in a 1 2 3 4 5 Ncomprehensive and specific manner thatemphasizes strengths and deficits in behavioralterms.

50


G. Goal setting that reflects the client’s perspective 1 2 3 4 5 Non wants and needs.

H. Planning for interventions and services that will 1 2 3 4 5 Nassist the client in achieving his or her goals.

I. Intervening in ways that produce client progress 1 2 3 4 5 Nin achieving his or her behavioral and/or emotionalgoals.

J. Summarizing process dynamics, themes, activities, 1 2 3 4 5 Nand milestones in the counseling relationship.

K. Evaluating progress with the client on an ongoing 1 2 3 4 5 Nbasis as well as at points of termination or otherchanges in the counseling relationship.

IV. PROFESSIONAL ISSUES

A. Use of supervision, including preparation, 1 2 3 4 5 Nparticipation, and follow through.

B. Preparation of written reports, progress notes, 1 2 3 4 5 Nand correspondence, emphasizing clarity,organization, and professional presentation.

C. Understanding of ethical issues, including, for 1 2 3 4 5 Nexample, confidentiality, representation ofcompetence and qualifications, loyalties, andinformed consent.

D. Identified personal values and beliefs that may 1 2 3 4 5 Nimpact on ability to fill the role of rehabilitationcounselor.

E. Engages in self exploration. 1 2 3 4 5 N

F. Recognizes personally sensitive areas in counseling 1 2 3 4 5 Ncontent and/or process.

G. Controls and explores own feelings and personal 1 2 3 4 5 Nthoughts about clients to increase understandingand to decrease interference in the counselorrelationship.

51


H. Requests guidance as needed while demonstrating 1 2 3 4 5 Nan openness to experimentation and risk taking.

I. Evaluates relevance, value, and meaning of feed- 1 2 3 4 5 Nback and implements changes as needed.

J. Sets career goals. 1 2 3 4 5 N

III. SELF AWARENESS

A. Sets personal learning goals 1 2 3 4 5 N

B. Evaluates progress towards personal goals. 1 2 3 4 5 N

C. Gives an accurate and balanced self-assessment 1 2 3 4 5 Nof professional competencies.

Circle your overall rating for your internship experience.

Circle your overall rating for this student for his/her internship experience.


1 2 3 4 5 N

Signed: ___________________________________ Student Signature

Mail and fax to:

Faculty Supervisor (add faculty supervisors name here)Masters of Rehabilitation Counseling ProgramTexas Tech University Health Sciences CenterSchool of Allied Health Sciences3601 4th St STOP 6225Lubbock, TX 79430FAX: 806-743-3244


52


SITE SUPERVISOR EVALUATION OF REHABILITATION

EDUCATION PROGRAM

The Master’s of Rehabilitation Counseling Program at Texas Tech University Health Sciences Center is dedicated to the improvement of educational services, and relationships with clinical service providers. As such, we appreciate your taking a few moments to help in our program evaluation process. This information is for program internal purposes only. It will not impact the involvement of future interns with your agency, nor will it be shared with the student.

Agency Representative / Site Supervisor:______________________________________

Agency:_________________________________________________________________

Faculty Contact:__________________________________________________________

Directions: Please rate each item by selecting the appropriate number (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree, N/A = not applicable).

1. I felt that MRC Faculty established communication with our agency, and especially with the site supervisor.

1 2 3 4 5 N/A

2. MRC Faculty was readily available for consultation and information sharing.

1 2 3 4 5 N/A

3. I felt that MRC Faculty heard and addressed any concerns I had.

1 2 3 4 5 N/A

4. Procedures and expectations were clearly explained. 1 2 3 4 5 N/A

5. I would recommend to other agencies and individuals to work with this rehabilitation education program and their students.

1 2 3 4 5 N/A

6. I felt supported by the MRC faculty in my role as supervisor.

1 2 3 4 5 N/A

7. My overall experience working with this rehabilitation counseling education program was positive.

1 2 3 4 5 N/A

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8. Please provide any additional comments you feel would be beneficial for our evaluation process. Feel free to add additional pages as needed.

Mail and fax to:

Faculty Supervisor (add faculty supervisors name here)Masters of Rehabilitation Counseling ProgramTexas Tech University Health Sciences CenterSchool of Allied Health Sciences3601 4th St STOP 6225Lubbock, TX 79430FAX: 806-743-3244


54

Documents

Introduction - Texas Tech University Health Sciences …soahs1.ttuhsc.edu/mrc/documents/Practicum_Internship... · Web viewCircle your overall rating for your internship experience