Placement Site:
Date of Field Placement:
Supervisee completes this form at the end of the field experience. This should be turned in to the university supervisor or
internship coordinator as indicated by the university program.
Rate the following questions about your site and experiences with the following scale:
A. Very satisfactory B. Moderately satisfactory C. Moderately unsatisfactory D. Very unsatisfactory
1. ________ Amount of on-site supervision
2. ________ Relevance of experience to career goals
3. ________ Exposure to and communication of site goals
4. ________ Exposure to and communication of site policies/regulations/procedures
5. ________ Exposure to professional roles and functions within the setting
6. ________ Exposure to information about community resources
7. ________ Administrative support for the site counseling program
8. ________ Appropriate supervisee office space and working conditions
9. ________ Appropriate support by site of the supervisee
Using the same scale as above, rate all applicable experiences that you had at your site. Leave a blank
space for experiences you did not have. Feel free to comment about specific experiences.
________ Report writing/record keeping/counseling notes
________ Intake interviewing
________ Programming/planning activities
________ Staff presentations/case conferences /staff development workshops
________ Individual counseling
________ Group counseling
________ Family/couple counseling
________ Support team, collaboration with other professionals
________ Career counseling
________ Program evaluation
________ Other ________________________________________
________ Other ________________________________________
Comments: Include any suggestions for improvements in the experiences you have rated
moderately (C) or very unsatisfactory (D).
Based on your practicum/internship experience, select one of the following statements:
___ I wholeheartedly recommend this site for future students.
___ I recommend this site for future students.
___ I recommend this site, with reservations, for future students.
___ I do not recommend this site for future students.
Explain your statement: