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School and Clinical Child Psychology Program

CLINICAL COURSE-BASED EVALUATION FORM

This form provides the Director of Clinical Training (DCT) with a record of students’ clinical skills development as well

as helping students keep track of the total number of hours of clinical experience that they have obtained. This form

provides a structure that helps to do this. It should be completed for all SCCP courses that involve direct client contact

(e.g., 1216, 5284, 3240 and sometimes for 3222). This form should be handed out at the beginning of the practicum

courses. Students should make a copy and give the original to the DCT. The DCT will file the form in the students’ files.

Please be advised that this form pertains only to program-sanctioned training or work experiences. If you have obtained

additional, relevant work experience, these hours can be documented elsewhere (on another form).

A further function of this form is to formally monitor the early clinical performance of students in course 1216 to ensure

that each student is ready for a practicum placement.

Please fill out the following information:

Name of Student Student Number

Name of Supervisor

Name of Course

Time Period From: To:

GENERAL INSTRUCTIONS:

• Sections 1& 2 are to be filled out by the student & reviewed by the supervisor. Section 3 is to be filled out by the supervisor.

SECTION 1

1. INTERVENTION AND ASSESSMENT EXPERIENCE (DIRECT SERVICES) How much experience do you have with different types of psychological interventions and assessment?

For this question (Question 1), please summarize professional activities that you have provided in the presence of a client /

patient. Professional activities that are not provided in the presence of a client should be summarized in Question 4 (Support

Activities). Activities that pertain to a client / patient but did not take place in the presence of the client / patient (e.g., gathering

information about a client / patient), should be recorded in Question 4 (Support Activities).

When quantifying your practicum experience, you must use your best judgment of the time spent in different activities and the

number of clients / patients seen. If an exact number is not available, please use a best estimate and consult with your training

director as needed.

o A practicum hour should be a full clock hour, not a partial hour. However, a 45-50 minute client/patient meeting can

be counted as a full practicum hour.

o Unless otherwise indicated, please note that the categories are intended to be mutually exclusive; that is, a practicum

hour counted in one section should not be counted in another section as well. Some experiences might seem to fall

under more than one section; however, you must decide which section best captures the experience and record your

time in this section. (For example, a Relaxation group might be classified as a ‘group,’ or a ‘Medical / Health-

Related Intervention,’ but not both.)

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o When documenting an hour spent with a group of clients / patients (e.g., a couple, family, group), this should be

recorded as one hour in total (i.e., do not count an hour for each separate person in the group).

o In the “# of different…” category, please count a group (e.g., a couple, family, group) as one (1) unit. For example,

if a student met with a group of 10 clients / patients for an hour session over a period of 8 weeks, this would count as

8 hours and one (1) group. A group with open membership is also counted as one (1) unit.

Before completing this table, please review the guidelines above.

List (if any) the type of therapy or counseling you provided

(e.g., Individual Therapy, Group Counseling, Family Therapy)

Total hours

face-to-face

# of different

INDIVIDUALS

In this space, list the ages of the client(s):

h. Psychological Assessment Experience: This is the estimated total hours spent administering tests to clients / patients,

face-to-face. Also include in this section the total hours spent providing feedback to clients / patients. However, do not

include time spent scoring tests or report writing; the latter activities can be documented in the Question 4 (Support

Activities). Information about the number of tests scored will be recorded elsewhere (in Section 2).

PSYCHOLOGICAL ASSESSMENT EXPERIENCE

Total hours

face-to-face

1) Psychodiagnostic test administration (include symptom assessment,

projectives, personality, objective measures, achievement, intelligence

and career assessment), and providing feedback to clients / patients.

2) Neuropsychological Assessment (include intellectual assessment in

this category only when it was administered in the context of

neuropsychological assessment involving evaluation of multiple

cognitive, sensory, and motor functions).

3) Other (please specify):

2. SUPERVISION RECEIVED

Please summarize the amount of time you have spent receiving supervision from the different health care professionals listed in

the table below. Note that ‘supervision’ is defined as the overseeing, by a health care professional, of psychological services

rendered by the student. Supervision involves and evaluative component and the discussion of specific cases (e.g., supervisor’s

feedback on an assessment plan or formulation presentation). Didactic portions of training should be documented in Question 4

(Support Activities); e.g., lectures would not be counted in this category.

o Individual and group supervision are listed separately in the table. Individual supervision is one-on-one, face-to-face

supervision.

o Group supervision can include feedback received from the supervisor in class, and discussion of cases in class with

the supervisor present

.

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Before completing this table, please review the above guidelines.

Supervision provided by

Licensed Psychologists /

Allied Mental Health

Professionals

Supervision provided by

Advanced Grad Students

Supervised by Licensed

Psychologists (e.g., TA) Total Supervision Hours

a. Individual

Supervision Received

b. Group Supervision

Received

3. INFORMATION ABOUT YOUR PRACTICUM EXPERIENCES

a. Treatment Settings

All your hours were likely obtained through the Department Clinic (OISE Psychology Clinic). If some of your hours were obtained in

another setting, please explain your situation:

b. What kind of groups (if any) did you lead / co-lead?

Describe the type of group, the duration of the group, and the average number of clients present at each session.

c. Have you ever audiotaped, videotaped, or made digital recording of clients / patients and reviewed these with

your clinical supervisor?

Yes No

d. In the table below, record the number of clients / patients you have worked with (therapy, counseling, or assessment) who

are members of the diverse populations listed in the table below. In the ‘Assessment’ column, please include clients /

patients for whom you performed assessments or intake interviews.

For this question, you can indicate a client / patient more than once if he / she fits in more than one row or

column. In terms of groups (e.g., couples, families, or groups), you can count each individual as a separate unit.

RACE / ETHNICITY Number of Different Clients / Patients Seen

Intervention Assessment

Black Canadian / African American / African Origin

Asian Canadian / Asian Origin / Pacific Islander

Latino-a / Hispanic

Indigenous (North American)

European Origin / White

Multi-racial

Other (please specify)1:

1 Consider mentioning work with clients who are learning English (ELL), or children who are enrolled in French Immersion.

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SEXUAL ORIENTATION Number of Different Clients / Patients Seen

Intervention Assessment

Heterosexual

Gay

Lesbian

Bisexual

Other (please specify):

DISABILITIES Number of Different Clients / Patients Seen

Intervention Assessment

Physical / Orthopedic Disability

Blind / Visually Impaired

Deaf / Hard of Hearing

Learning / Cognitive Disability

Developmental Disability (Including Autism)

Serious Mental Illness (e.g., primary psychotic disorders, major

mood disorders that significantly interfere with adaptive

functioning)

Other (please specify):

GENDER Number of Different Clients / Patients Seen

Intervention Assessment

Male

Female

Transgender

Other

4. SUPPORT ACTIVITIES In this section, record the hours spent in activities that supported the intervention / assessment experiences.

In Question 4, please summarize professional activities that pertain to clients / patients but did not take place in the presence of

clients / patients. Support activities include: gathering information about a client / patient outside of a session, providing distance

interventions (e.g., by telephone or webcam), learning about tests, scoring tests, report writing, observing other professionals

testing, reviewing video tapes of assessment sessions, and consulting with teachers / other professionals (e.g., class hours spent

listening to classmates’ assessment plans). Didactic portions of training should also be documented here (e.g., presentations,

lectures and/or ‘Grand Rounds’).

TOTAL HOURS SPENT IN SUPPORT ACTIVITIES:

Below, please indicate which activities comprised the support hours recorded in the above box:

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SECTION 2

1. TEST ADMINISTRATION

In the two tables that follow, please record which instruments you administered and scored in your practicum / internship.

Separate tables are provided for instruments used with adults and children, respectively. Do not count practice administrations in

the table.

o In the first column of the table, indicate which tests you administered and scored. A sample list of tests is

provided below, but please feel free to include tests that are not mentioned in this list. o In the second column, indicate the number of tests that you administered and scored. In the third column, indicate

how many of those that you administered and scored in column one were subsequently interpreted in a report that

you wrote. EXAMPLES OF PSYCHOLOGICAL INSTRUMENTS Autism Spectrum Rating Scale-2

Bayley Scales of Infant Development-3

BASC-3

BRIEF-2

Bender Gestalt

Benton Visual Retention Test-2

Boston Naming Test

California Verbal Learning Test

Children’s Memory Scale (CMS)

Comprehensive Test of Phonological

Processing (CTOPP-2)

Conners 3rd Edition Dementia Rating Scale-II

D-KEFS

Expressive Vocabulary Test (EVT-2)

Human Figure Drawing

Kinetic Family Drawing

Millon Adolescent Clinical Inv. (MACI-IV)

Millon Clinical Multi-Axial Inv. (MCMI)

Myers-Briggs Type Indicator

Multilingual Aphasia Exam

MMPI-2 RF, MMPI-A

Parent Report Measures (e.g., CBCL)

Personality Assessment Inventory (PAI)

Projective Sentences / Sentence Completions

Peabody Picture Vocabulary Test (PPVT-4)

Projective Drawings (includes Draw-a-Person

Test and Kinetic Family Drawing)

Rorschach (Specify scoring system)

Rey-Osterrieth Complex Figure

Roberts Apperception Test for Children

Self-report measures of symptoms / disorders

(e.g., Beck Depression Inventory,

Multidimensional Anxiety Scale for Children)

SCID-5

Structured Diagnostic Interviews

Strong Interest Inventory

Thematic Apperception Test

Trail Making Test A & B

WIAT-III

WRAML-2

WISC-V

Woodcock Johnson-III (Ach, Cog)

WPPSI-III

WRAT-5

WAIS-IV

Wechsler Memory Scale (WMS-IV)

Wisconsin Card Sorting Test

1. NAME OF TEST

# ADMINISTERED AND

SCORED

# OF REPORTS

WRITTEN

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2. INTEGRATED REPORT WRITING – How many supervised, integrated, psychological reports have you written for adults / children?

A report is considered ‘integrated’ if it satisfies the following criteria:

• Includes a history,

• Includes an interview,

• Includes at least 2 tests from one or more of the following categories:

o Personality assessments (objective, self-report, and/or projective)

o Intellectual assessment

o Cognitive assessment

o Neuropsychological assessment

• The final report integrates the abovementioned sections to provide a comprehensive, overall picture of the client /

patient.

3. INTEGRATED REPORT WRITING

# INTEGRATED

REPORTS

a. Adults

b. Children / Adolescents

In this space, list the ages of the client(s):

3. TOTAL SUMMARY OF HOURS (please add to page 10)

SECTION 3

Student Performance Evaluation

Note to supervisors: Ratings should be based, in part, on direct observation. Scores of 1 and 2 are considered

problematic. Select the rating that best corresponds to how characteristic the student’s behaviour is of the

competency descriptions below.

Rarely

1

Occasionally

2

Usually

3

Very Often

4

Always

5

Insufficient Basis

IB

1=Rarely: The student rarely demonstrates mastery of this competence and requires additional course-based

instruction or practical experience to develop this skill. A student who is consistently rated at this level will need to

be reviewed and the student’s suitability for their field of work should be re-evaluated.

2=Occasionally: The skill is demonstrated occasionally and the student requires extra practice in this competency

prior to beginning internship. A student who is consistently rated at this level should be recommended for an

extension of his/her practicum or internship requirement.

3=Usually: The skill is usually demonstrated by the student and they should continue to develop this competency

with supervision and/or mentoring.

4=Very Often: The skill is very often demonstrated by the student and is well developed.

5=Always: The skill is always demonstrated and the student’s skills in this area are exceptionally strong. The student

could serve as a model to other students in this area.

IB=Insufficient Basis for Making a Rating

(a) the target activities are not typically carried out at the field placement;

(b) the student has not engaged in the target activities;

(c) a previous supervisor is unavailable for consultation; or

(d) the supervisor has not had the opportunity to observe and evaluate the student

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1. PROFESSIONALISM/INTERPERSONAL RELATIONSHIPS

Insufficient

Basis

Rarely Occasionally Usually Very

Often

Always

Work Habits

Is punctual

IB 1 2 3 4 5

Plans work thoroughly

IB 1 2 3 4 5

Manages time effectively

IB 1 2 3 4 5

Makes efficient use of supervision time

IB 1 2 3 4 5

Generates new and useful ideas

IB 1 2 3 4 5

Works at an appropriate level of

independence for training level

IB 1 2 3 4 5

Comes to supervision well-prepared and

able to use time effectively

IB 1 2 3 4 5

Decision Making

Makes difficult or non-routine decisions

IB 1 2 3 4 5

Recognizes own limits and appropriately seeks the advice of others when needed

IB 1 2 3 4 5

Assumptions of Responsibilities

Takes charge of situations and gets

things done

IB 1 2 3 4 5

Meets deadlines promptly

IB 1 2 3 4 5

Recognizes problem situations and deals

with them effectively

IB 1 2 3 4 5

Interpersonal Skills

Forms and maintains productive and

respectful relationships with clients,

peers/colleagues, supervisors and

professionals from other disciplines

IB 1 2 3 4 5

Negotiates differences and handles

conflict satisfactorily; provides effective

feedback to others and receives feedback

nondefensively

IB 1 2 3 4 5

Communication and physical conduct is

professionally appropriate, across

different settings

IB 1 2 3 4 5

Displays emerging professional identity

as psychologist; uses resources (e.g.,

supervision, literature) for professional

development

IB 1 2 3 4 5

Deals with personal crises in a way that

does not interfere inappropriately with

clinical work

IB 1 2 3 4 5

Comments on professionalism/interpersonal relationships:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

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2. ASSESSMENT AND EVALUATION SKILLS

Insufficient

Basis

Rarely Occasionally Usually Very

Often

Always

Establishes rapport with patients/clients

IB 1 2 3 4 5

Is insightful into client difficulties

IB 1 2 3 4 5

Demonstrates good interviewing skills

(e.g., clinical, intake)

IB 1 2 3 4 5

Demonstrates good observational skills

IB 1 2 3 4 5

Formulates appropriate questions to be

addressed by assessment

IB 1 2 3 4 5

Selects appropriate tests for assessment

IB 1 2 3 4 5

Demonstrates breadth & knowledge

regarding assessment materials

IB 1 2 3 4 5

Accurately and skillfully administers and

scores tests

IB 1 2 3 4 5

Interprets & integrates assessment

findings appropriately

IB 1 2 3 4 5

Demonstrates solid knowledge and application of diagnosis

IB 1 2 3 4 5

Relates assessment findings to

recommendations

IB 1 2 3 4 5

Produces quality written reports

IB 1 2 3 4 5

Effectively communicates results of

assessment to clients and/or relevant

others

IB 1 2 3 4 5

Manages client files effectively (e.g.,

produces appropriate notes and records

for client files)

IB 1 2 3 4 5

Comments on assessment & evaluation skills:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

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3. INTERVENTION AND CONSULTATION

Insufficient

Basis

Rarely Occasionally Usually Very

Often

Always

Establishes rapport with patients/clients

IB 1 2 3 4 5

Is insightful into client difficulties

IB 1 2 3 4 5

Demonstrates good interviewing skills

(e.g., clinical, intake)

IB 1 2 3 4 5

Demonstrates good observational skills

IB 1 2 3 4 5

Demonstrates knowledge of

psychoeducational intervention techniques

IB 1 2 3 4 5

Applies psychoeducational intervention

techniques

IB 1 2 3 4 5

Keeps appropriate records of

therapy/intervention progress

IB 1 2 3 4 5

Evaluates ongoing progress during

therapy/intervention

IB 1 2 3 4 5

Manages client file effectively (e.g.,

produces appropriate notes and records

for files)

IB 1 2 3 4 5

Comments on intervention & consultation: _______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

4. INTERDISCIPLINARY SYSTEMS

Insufficient

Basis

Rarely Occasionally Usually Very

Often

Always

Demonstrates beginning, basic knowledge

of the viewpoints and contributions of

other professions/professionals

IB 1 2 3 4 5

Demonstrates beginning knowledge of

strategies that promote interdisciplinary

collaboration vs. multidisciplinary

functioning

IB 1 2 3 4 5

Demonstrates knowledge of how

participating in interdisciplinary

collaboration/consultation can be directed

toward shared goals

IB 1 2 3 4 5

Develops and maintains collaborative

relationships and respect for other

professionals

IB 1 2 3 4 5

5. ETHICS Insufficient

Basis

Rarely Occasionally Usually Very

Often

Always

Familiar with ethical standards for IB 1 2 3 4 5

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psychologists, understands their

implications, and acts accordingly

Demonstrates responsibility to clients,

society, the profession and colleagues

IB 1 2 3 4 5

Knowledgeable of jurisprudence and local

regulations

IB 1 2 3 4 5

Aware of and able to deal appropriately

with professional biases and beliefs (e.g.,

gender, race, homophobia)

IB 1 2 3 4 5

Knowledgeable of factors that may

influence the professional relationship

(e.g., boundary issues)

IB 1 2 3 4 5

Deals appropriately with ethical dilemmas

IB 1 2 3 4 5

Demonstrates familiarity and appreciation

of confidentiality issues

IB 1 2 3 4 5

Knowledgeable of standards for

psychological tests, measurements and

intervention

IB 1 2 3 4 5

Comments on Ethics:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

6. INDIVIDUAL AND CULTURAL DIVERSITY

Insufficient

Basis

Rarely Occasionally Usually Very

Often

Always

Monitors and applies knowledge of self as

a cultural being in assessment, treatment,

and consultation

IB 1 2 3 4 5

Applies knowledge of others as cultural

beings in assessment, treatment, and

consultation

IB 1 2 3 4 5

Applies knowledge of the role of culture

in interactions in assessment, treatment,

and consultation of diverse others

IB 1 2 3 4 5

Applies knowledge, sensitivity, and

understanding regarding ICD issues to

work effectively with diverse others in

assessment, treatment, and consultation

IB 1 2 3 4 5

Is sensitive to multicultural issues and the

range of diversity (e.g. gender,

socioeconomic) in assessment

IB 1 2 3 4 5

Is sensitive to multicultural issues and the

range of diversity (e.g. gender,

socioeconomic) in intervention

IB 1 2 3 4 5

Comments on Individual and Cultural Diversity:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

7. REFLECTIVE PRACTICE

Insufficient

Basis

Rarely Occasionally Usually Very

Often

Always

Displays broadened self-awareness (i.e., IB 1 2 3 4 5

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self-monitoring, reflection regarding

professional practice, utilization of

resources to enhance reflectivity)

Effectively participates in supervision in a

truthful, factual, and respectful manner

IB 1 2 3 4 5

The following items are for PhD students only:

Demonstrates broad and accurate self-

assessment of competence (i.e., monitors

and evaluates practice activities;

recognizes limits of knowledge/skills,

seeks means to enhance knowledge/skills)

IB 1 2 3 4 5

Monitors issues related to self-care with

supervisor and understands the central role

of self-care to effective practice

IB 1 2 3 4 5

Comments on Reflective Practice:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Additional comments or concerns regarding this student’s clinical progress in the above course: _______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________ TOTAL SUMMARY OF HOURS

a. Total Intervention Hours

a. Total Assessment Hours

a. Total Intervention and Assessment Hours

(Question 1)

b. Total Supervision Hours

(Question 2)

c. Total Hours Spent in Support Activities

(Question 5)

TOTAL HOURS OF CLINICAL

EXPERIENCE

(Question 1 + 2 + 5)

SUPERVISORS MUST SIGN BELOW, WITH THE EXCEPTION OF 1216 SUPERVISORS, WHO MUST COMPLETE & SIGN

THE FOLLOWING PAGE.

Signature of Supervisor Date

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SECTION 4

FOR 1216 ONLY

The Supervisor of 1216 must complete the following

SUMMARY OF STUDENT CLINICAL PERFORMANCE FORM

PSYCHOLOGICAL ASSESSMENT

Course: 1216

Section # Course Date (year/term)

❑ Overall, in my opinion: This student’s performance is satisfactory. He/she is ready for a practicum placement.

❑ Although I have one/some minor concern(s) in one/some area(s) of clinical practice, I basically feel that this student

is ready for a practicum placement

❑ I have one or more major concerns regarding this student’s clinical practice. I am not sure that this student is ready

for a practicum placement.

❑ I have pronounced concerns and do not feel that this student is ready for a practicum placement.

Comments:

Signature of Supervisor Date

STUDENT MUST COMPLETE: I acknowledge that I have reviewed this form together with my course instructor:

Signature of Student Date

Note: Students should make a copy for their records and also submit a hard copy to the Director of

Clinical Training with original signatures.

Updated: August 2019