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CC Site Supervisor Manual
1
Georgia Southern University
College of Education
Community Counseling Program
Internship Manual for
Site Supervisors
COUN 7738: Counseling Internship I
COUN 7739: Counseling Internship II
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TABLE OF CONTENTS
I. Internship General Description ……………………………………….. p. 4
II. Course Outline …………………………………………………………. p. 4
III. CACREP Standards ……………………………………………………. p. 6
IV. Guidelines and Policies ………………………………………………... p. 7
V. Procedures………………………………………………………………. p. 8
VI. Counseling Forms……………………………………………………….. p. 14
Analysis of Counseling Session
Client Release Form
Parental Release Form
VII. Forms to be Submitted to University Supervisor…………………….. p. 16
Internship Request Form
Information Data Sheet
Objectives for Internship
VIII. Forms to be Signed and Submitted to University Supervisor………... p. 17
Counseling Internship Agreement (4 copies needed)
Student Internship Agreement (2 copies needed)
Internship Time Sheet (1 copy needed for each month)
Checklist for monthly activities
IX. Evaluation Forms……………………………………………………….. p. 24
Site Evaluation Form
Intern Performance Evaluation
Intern Evaluation of Supervisor
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To the Community Supervisor:
We appreciate your willingness to serve as a supervisor for an intern from the
Community Counselor program at Georgia Southern University. It is our intent to
provide you with an intern who is well prepared and an appropriate placement for your
agency. With the team approach between yourself, the intern, and the University
Supervisor, we trust the experience will be both positive and productive. We understand
how busy you are, however, we ask you to carefully read the following pages to ensure
we are all in agreement about the objectives, procedures, and attitudes that will make the
internship process successful.
The Community Counseling Internship Manual for Site Supervisors has been designed to
provide Internship site supervisor’s detailed and relevant information about field
experiences for the Community Counseling program in the department of Leadership,
Technology, and Human development (LTHD) at Georgia Southern University. The
counseling faculty considers these field experiences to be among the most important for
our community counseling students. We hope this manual will be helpful in answering
some commonly asked questions about Internship.
Again, thank you for your participation in this experience to help Georgia Southern’s
st
community counselors-in-training to work in the 21 Century as professional counselors.
Website: http://coe.georgiasouthern.edu/lthd/counselored.html
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Description of Internship
COUN 7738 & 7739
The Internship is an intensive field-based experience for candidates in the master’s
degree program in community counseling. Community counselors-in-training will
integrate advanced competencies and knowledge with professional supervision.
Placements occur in both public and private agency settings. Application for the
internship and approval for placement are required prior to registration. A minimum of
six hundred (600) hours in internship placement is required. The grading system is
credit/no credit. Prospective interns needed to have completed the COUN 7737 Practicum
course before beginning the internship. Internship is normally taken at or near the end of
the program of study, after the Practicum experience.
Master’s Degree in Education emphasis in Community Counseling
The Community Counseling Program provides competencies for entry-level positions as
professional counselors in community agency settings. Upon completion of the graduate
program of study, students complete all academic requirements for licensing as a
Licensed Professional Counselor. In addition to coursework in core counseling skills,
process, and theory, specialized coursework focuses on addiction counseling, family
counseling, assessment, implementation and evaluation of counseling programs, ethical,
legal, and professional issues in community counseling.
Following are the courses a student must complete to earn the Master’s Degree:
1) Foundations of Community Counseling
and Ethics
2) Group Dynamics
3) Family Counseling
4) Theories of Counseling
5) Counseling Assessment, Diagnosis and
Intervention
6) Models/Techniques of Counseling
7) Addiction Counseling
8) Practicum in Counseling
9) Career Counseling
10) Counseling Internship
11) Cross Cultural Counseling
12) Counseling Internship
13) Life Span Development
14) Learning Theories &Applications
15) Individual Analysis
16) Educational Research
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More information about the program is available on the Counselor Education website at:
www.georgiasouthern.edu/lthd/counselored ; or call the departmental office at (912) 478-5307.
Student Intern Time Commitment for Internship I and II
Internship I Internship II
1. Direct Service – 240 hrs 120 in an agency setting 120 in an agency setting
2. Supervision On-Site– 30 hrs 1 hour per week (15 weeks) 1 hour per week (15 weeks)
3. University Supervision- 45hrs 1 ½ hours per week (15) 1 ½ hours per week (15)
4. Other Hours – 385hrs 192 ½ hours 192 ½ hours
Total Hours for two internships: 600
1. Direct Service:
Hours include individual, group and family counseling, prevention activities, advocacy and consultation. As well as
counting the intern’s own service, they may also receive direct service hours when the intern is observing someone else
conducting these activities.
2. Site Supervision:
At least one hour of supervision per week must be face-to-face one hour individual supervision between the site
supervisor and the intern. Georgia Southern strongly recommends these meetings occur in a quiet office without
interruption.
3. University Supervision:
The intern is required to attend a Counseling Internship class for the academic year. The intern may count the hours as
listed above.
4. Other Hours:
These hours include professional development activities, additional training experiences, any related readings, duty at
other on-site and agency community activities (e.g. community service board /collaborative meetings, open houses, etc.).
Internship class but may not count as direct service hours until the university internship class begins (under direct
University supervision). Students are expected to remain at their placement sites for the entire school term. The number of
hours spent at the intern’s site varies according to the needs of the site and the students. Typically, interns can expect to
spend about 20 hours per week at each site.
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CACREP Standards
The Council for Accreditation of Counseling and Related Educational Programs (CACREP) standards are the
guidelines for use in implementing internship. Because Georgia Southern University’s school counseling
program is designed to meet CACREP standards, it is essential that both the internship site and the overall
internship experience adhere to the following standards.
The CACREP standards require a supervised internship of 600 clock hours, which include the following:
1. A minimum of 240 hours of direct service with clients appropriate to the program of study,
2. A minimum of one hour per week of individual supervision throughout the internship performed by the on-
site supervisor,
3. A minimum of one and one-half hours per week of group supervision provided on a regular schedule
throughout the internship, usually performed by a program faculty member,
4. The opportunity of the counselor-in-training to become familiar with a variety of professional activities other
than direct service,
5. The opportunity for the counselor-in-training to develop audio and/or videotapes of the student’s interactions
with clients appropriate to the specialization for use in supervision,
6. The opportunity for the counselor-in-training to gain supervised experience in the use of a variety of
professional resources such as assessment instruments, computers, print and non-print media,
professional literature, research, and information and referral to appropriate providers,
7. A formal evaluation of performance during internship by a program faculty supervisor in consultation with
the site supervisor.
Council for Accreditation of Counseling and Related Educational Programs (CACREP).
(2001). The 2001 standards [Electronic version]. Retrieved July 27, 2008, from
http://www.cacrep.org/2001Standards.html
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CACREP curriculum area standards are identified as:
1. Human Growth and Development: Completion of the program will provide the student an understanding of
the major theories of human growth and development; how human behavior and environmental factors affect
both normal and abnormal behavior in both the school and community agency setting.
2. Social and Cultural Foundations: Completion of the program will provide the student an understanding of
issues and trends in a multicultural and diverse society. These considerations are based upon human attitudes
and behavior toward such factors as age, race, religious preference, physical disability, sexual orientation,
ethnicity and culture, family patterns, gender, socioeconomic status, and intellectual ability.
3. Helping Relationships: Completion of the program will provide the student an understanding of counseling
and consultation processes such as basic interviewing, assessment, and counseling skills. Other helping
considerations include knowledge of counselor, consultant, and client characteristics; as well as behaviors that
influence the helping process.
4. Group Work: Completion of the program will provide the student an understanding of group development,
dynamics, counseling theories, group counseling methods and skills, and other group work approaches.
5. Lifestyle and Career Development: Completion of the program will provide the student an understanding of
career development and related life factors such as the career decision-making process and interrelationships
among work, family and other life roles including multicultural and gender issues as related to career
development.
6. Appraisal: Completion of the program will provide the student an understanding of individual and group
approaches to assessment and evaluation.
7. Research and Evaluation: Completion of the program will provide the student an understanding of types of
research methods, basic statistics, and ethical and legal considerations in research.
8. Professional Orientation and Ethics: Completion of the program will provide the student an understanding of
all aspects of professional functioning including history, roles, organizational structures, ethics, standards, and
credentialing.
9. Specialization: Completion of the program will provide the student knowledge and competence in the basic
skills for entrance into the counseling profession specialization of his or her program.
For your information, the intern will evaluate their site placement and supervision.
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The Role of the Supervisor
The mindset and functions of a supervisor are similar to but not the same as a counselor. Indeed, your role will
be unique, as it pertains to:
1) Your background, expertise, and personal approach;
2) The background, expertise, and personal approach of the intern (he/she may
already have had counseling experience – or may still be in the process of
identifying a ―style‖ as a counselor);
3) And the particular circumstances of your agency setting (size; demographics;
counselor/client ratio; administrative and other support; special needs;
and other factors).
The supervisor plays three roles:
1) Counselor – participating with the intern in self-exploration; establishing
distance; becoming aware of one’s values and possible biases; and confronting
the range of emotions that inevitably occur.
2) Teacher – imparting new knowledge; refining skills as requested by the intern
or as the occasion calls for; inquiring about the cognitive theoretical orientation
of the intern; demonstrating by example as a role model; assuring the intern has a
range of experiences; and observing and providing feedback on performance.
3) Consultant – meeting weekly with your intern, responding to intern special
request for a conference to discuss a specific counselee, or approach/ technique
the intern utilized; emphasizing on professional commitment and improvement.
Site Supervisor Responsibility Checklist
1. Submit a copy of your license/certificate to the Clinical Coordinator to verify you meet
the criteria for selection as a site supervisor.
2. Sign the agreement form (to be provided by intern) and provide a copy of your resume
to the Clinical Coordinator (your intern can deliver it) within two weeks of
placement of the intern at your site.
3. Meet one hour face-to-face each week with your counselor intern in a quiet and
uninterrupted location.
4. Attend all supervisor trainings. The Georgia Southern University Counselor Education
Program offers training in supervision for site supervisors each semester.
5. Complete the Site Supervisor and Director’s Evaluations of Counseling
Intern’s Performance to indicate your professional assessment of the counseling intern’s
demonstrated knowledge, skills, and competencies. Review them with the intern.
6. Each month review the Internship Time Sheet that the counseling interns will be
required to fill out. Please sign to confirm your concurrence.
7. Provide experience for the counseling intern to job shadow you and other key faculty
members.
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8. Provide the intern with experience in co-leading and leading individual, psycho-educational,
and group counseling activities. Provide feedback to intern based on your observations.
9. Provide the intern with experience in observing and conducting consultation sessions
with staff, other agencies, and community representatives.
10. For your information, the intern will evaluate their site placement and supervision
experience at the end of the year. Georgia Southern University will use this information to evaluate the
effectiveness of the placement and address concerns. You will find a Site Evaluation Form and a Student
Counselor Evaluation of Supervisor in the Student Internship manual.
Suggestions for Interns Transitioning to the Site
Site Supervisor will introduce intern to:
�� Agency and unit personnel
��Key staff members
�� Administrative team
�� Staff (who will assist with coordination of referrals, communications, etc.)
�� Other community resources or individuals who are interactive with the agency
Site Supervisor the Intern will assist with:
�� Clinical observations
�� ―Team‖ counseling in the beginning
�� Intern observing (―shadowing‖) other counselors and key personnel
�� Development of groups with the intern as co-facilitator (e.g. psycho-educational, divorce, a, eating disorder, sexual
minority, etc.)
�� Attaining an intern caseload
�� Individual counseling (beginning early on with consultation/supervision around each session…daily ―debriefing‖)
�� Within 4 to 6 weeks, intern working independently with clients and groups in consultation with site supervisor
Site Supervisor will address:
�� Personal/social counseling…how/what
��Treatment planning…how/what
�� Counseling assessment
�� Crisis Intervention…who/how/what
�� Carefully outline procedures for special needs referrals and assistance
�� Policies and Procedures for the agency (e.g. mandatory reporting)
�� Importance of understanding the agency and the ―political climate‖
�� Role of the counselor within the agency (e.g. treatment team, staffing, advocacy etc.)
�� Role of the counselor and unit with administrative team and staff
�� Obtaining of resources…within the agency and from the community
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Supervisor will provide:
�� One-on-one weekly supervision—one hour uninterrupted
�� Physical area for individual counseling, and mailbox for agency communications
�� Clear understanding of weekly supervision time, criteria, method
�� Calendar of agency activities (e.g. staffing, counselor meetings, staff meetings, meetings with Community Service
Boards /collaboratives)
�� Counseling time management strategies and prioritization strategies for daily activities
�� Regular feedback on counseling activities…immediately and during weekly supervision…be specific…while allowing
the intern to ―brainstorm‖ what went wrong, what they would change, what was good.
�� A packet with all agency forms (e.g. referral, reporting, client information) and Employees Handbook.
�� Clear agreement around days of week for intern at site, time for supervision, preparation needed for supervision (e.g.
lists, video, questions/concerns).
�� Clear understanding of expectations for growth and individuality
�� Awareness of agency collaboratives/ partnerships.
Additional hints for Site Supervisors and interns:
�� Discuss diversity and cultural issues of agency and community…be clear and specific
�� Introduce resources frequently utilized
�� Do home visits (if appropriate)
Communication and Evaluation
You are encouraged to communicate with the University supervisor as frequently as you think is appropriate, by
telephone, e-mail, or personally. Ideally, we would enjoy connecting every three weeks or so. At supervisor seminars, you
will be asked to:
1) Review briefly your counseling program,
2) Share your philosophy and approach to the supervision of counseling interns, including ―success stories‖,
3) Raise general and specific questions regarding effective approaches/methods to use in difficult situations,
4) Suggest ways the counseling program in general, and the internship process in particular, could be
strengthened,
5) Raise other issues which you believe to be pertinent, and
6) Read and discuss current literature/research on the role of the community/mental health
counselor.
****
The following section outlines a remediation process to be used if the intern requires significant changes in personal
and/or professional behavior. The counseling faculty will be fully supportive of the agency supervisor and the intern in
arriving at the most beneficial solution for all individuals who are involved.
Remediation Tips for Your Intern
1) Address your concerns immediately. Do so in a caring and concerned manner, offering the intern time for reflection
and the opportunity to arrive at an alternative option.
2) Set a plan for correction if necessary. Make sure the intern is clear about expectations and steps for corrections.
3) Make the plan with the intern and brainstorm various solutions.
4) Develop short-term goals/objectives for the problem.
5) Develop long-term goals/objectives for the problem.
6) Put the plan in writing to be shared with the intern.
7) Include in the plan details for remedial supervision if necessary.
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8) Include in the plan how attainment will be demonstrated/documented.
9) If the above procedures are not working or other difficulties are becoming apparent, notify the University supervisor
IMMEDIATELY. Schedule a time for the university supervisor to visit first with you, and then with you and the
intern.
10) Georgia Southern wants the internship experience to be beneficial for both you and the intern. Therefore, please notify
the university supervisor immediately of concerns.
Criteria for Selection of Supervisor
A. Recognition of excellence in counseling from administrators, peers, and clients.
B. Commitment to quality.
C. Understanding of counselor’s role as supportive of the learning process.
D. Mature understanding of themselves as counselors, with sense of own professional efficacy and uniqueness.
E. Clear philosophy of counseling and learning.
F. Knowledge about, and respect for, the intellectual and social development of their clients, including differences and
similarities because of gender, race, ethnicity, social class, exceptionality, disabilities, linguistic experience, and sexual
orientation.
G. Interest in participating and committing time to the program.
H. At least Master’s Degree in Counseling or counseling related area.
I. At least three years of post-degree experience.
J. Experience in supervising students.
K. Familiarity with the Georgia Southern University Counseling Internship Manual.
L. Familiarity with, and implementation of the AMHCA (2000) and the ACA (2005) Codes of Ethics.
M. A current copy of the site supervisor’s résumé must be on file at Georgia Southern University Counseling Program
within two weeks of your intern’s arrival.
Finally….
University Supervisor Responsibilities
(1) Minimum of two site visits per semester;
(2) Small group supervision with intern;
(3) Video/audio tape review;
(4) Semester assessment of intern;
(5) Review of intern’s organizational analysis and data based intervention projects; and
(6) Support for both the intern and site supervisor during the year.
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CACREP Standards for Community Counseling Programs
In addition to the common core curricular experiences outlined in Section II.K, the following curricular experiences and
demonstrated knowledge and skills are required of all students in the program. Link to CACREP 2001 Standards -
http://www.cacrep.org/2001Standards.html
A. FOUNDATIONS OF COMMUNITY COUNSELING
1. Historical, philosophical, societal, cultural, economic, and political dimensions of and current trends in the
community human service/ mental health movement;
2. Roles, functions, preparation standards, credentialing, licensure and professional identity of community
counselors;
3. Policies, laws, legislation, recognition, reimbursement, right-to- practice, and other issues relevant to
community counseling;
4. Ethical and legal considerations specifically related to the practice of community counseling (e.g., the ACA
Code of Ethics); and
5. The role of racial, ethnic, and cultural heritage, nationality, socioeconomic status, family structure, age, gender,
sexual orientation, religious and spiritual beliefs, occupation, and physical and mental status, and equity issues in
community counseling.
B. CONTEXTUAL DIMENSIONS OF COMMUNITY COUNSELING
1. The roles of community counselors in various practice settings and the relationships between counselors and
other professionals in these settings;
2. Organizational, fiscal, and legal dimensions of the institutions and settings in which community counselors
practice;
3. Strategies for community needs assessment to design, implement, and evaluate community counseling
interventions, programs, and systems; and
4. General principles of community intervention, consultation, education, and outreach; and characteristics of
human services programs and networks (public, private, and volunteer) in local communities.
C. KNOWLEDGE AND SKILL REQUIREMENTS FOR COMMUNITY COUNSELORS
1. Typical characteristics of individuals and communities served by a variety of institutions and agencies that offer
community counseling services;
2. Models, methods, and principles of program development and service delivery for a clientele based on
assumptions of human and organizational development, including prevention, implementation of support groups,
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peer facilitation training, parent education, career/occupational information and counseling, and encouragement of
self-help;
3. Effective strategies for promoting client understanding of and access to community resources;
4. Principles and models of biopsychosocial assessment, case conceptualization, theories of human development and
concepts of normalcy and psychopathology leading to diagnoses and appropriate counseling plans;
5. Knowledge of the principles of diagnosis and the use of current diagnostic tools, including the current edition of
the Diagnostic and Statistical Manual;
6. Effective strategies for client advocacy in public policy and other matters of equity and accessibility;
and
7. Application of appropriate individual, couple, family, group, and systems modalities for initiating, maintaining,
and terminating counseling, including the use of crisis intervention, and brief, intermediate, and long-term
approaches.
D. CLINICAL INSTRUCTION
For the Community Counseling Program, the 600 clock hour internship (Standard III.H) occurs in a community
setting, under the clinical supervision of a site supervisor as defined by Section III, Standard C.1 - 2. The
requirement includes a minimum of 240 direct service clock hours.
The program must clearly define and measure the outcomes expected of interns, using appropriate professional
resources that address Standards A, B, and C (Community Counseling Programs).
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GEORGIA SOUTHERN UNIVERSITY
COUNSELOR EDUCATION PROGRAMS
Application For: COUN 7738 (Internship 1) ______ COUN 7739 (Internship II) ______
This application must be received by Internship Coordinator the semester prior to beginning your internship. A
clinical agreement must be processed for you before you begin your internship. You will be asked to provide
evidence of liability insurance and to inform the Internship Coordinator of any changes in your internship plans.
Purchase your "Internship Packet" at Printing Services, Williams Center.
Name: ____________________________________________________________________ SS#: _____________________________
Address: __________________________________________________________________ Phone #: ___________________________
_________________________________________________________________ Work #: ____________________________
Semester you will complete Counseling Practicum (COUN 7737): __________________________ Semester, 200_________
Total number of semester hours you will have completed prior to beginning internship: __________________________________________
Check COUN courses completed: 7331 7332 7336 7335 7337 7334 7333 7737
Check one: I am completing a degree ____________________________; adding certification ____________________________
Please indicate your primary interest area: School Counseling Community or Agency Counseling Higher Education
If School Counseling, Grade level(s) Preferred: Elementary Middle High Community
Today's Date: ____________________________ Plan to begin internship: ____________________________ Semester, 20__________
Number of semesters anticipated for internship? one two other
Internship Site Information: (Note: Complete a separate form for each site.)
System Superintendent or Agency Director to whom Clinical Contract should be mailed (not building principal):
Name: ___________________________________________________________________ Title: _________________________________
Phone #: (_____)________________________________________ Fax #: (_____)____________________________________________
Address: _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
City State Zip County
Name of Internship Site: _________________________________________________________________________________________
Internship Site Address: __________________________________________________________________________________________
On-Site Supervisor (Counselor): Name: _____________________________________________________________________________
Position: ______________________________________ Phone # (at work): ________________________________________________
Graduate Degree and Field: ________________________________________________________________________________________
Date Received by Internship Coordinator: _________________________
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Georgia Southern University
Counselor Education Program
Counseling Internship
(COUN 7738/7739)
Information Data Sheet
INTERN
Name: _______________________________________________________________________
Home Address: ________________________________________________________________
Name of Agency: _______________________________________________________________
Agency Address: _______________________________________________________________
Phone: Home: ____________________________ Agency: ______________________________
Mobile: ___________________________ Work: _______________________________
E-Mail Address: _______________________________________________________________
DIRECTOR
Name: _______________________________________________________________________
Agency Address: _______________________________________________________________
Fax #: _______________________________________________________________________
SPONSORING COUNSELOR
Name: _______________________________________________________________________
Agency Address: _______________________________________________________________
Sponsoring Counselor’s Phone: _____________________________________________
E-Mail Address: _______________________________________________________________
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Georgia Southern University
Counselor Education Program
Counseling Internship
(COUN 7738/7739)
Objectives for Internship
Intern's Name: ________________________________________________ Date: ____________
Community:
_______________________________________________________________________
List below your:
Objectives for Internship
Criteria for Attaining these Objectives
Intended Method of Documentation
Date of Attainment
Your objectives must fall within the following areas of counseling:
Program Development Prevention Counseling Consultation
Professional Activities Assessment Advocacy
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Georgia Southern University
Counselor Education Program
Counseling Internship Agreement
The Counselor Education Internship experience is a cooperative effort involving the
agency director, the sponsoring counselor, the counselor intern, and the Georgia Southern
University supervisor/instructor. The Internship experience will be effective if those
involved understand and accept the following responsibilities:
Responsibilities of the Director:
a. Allow the intern access to clients a minimum of 1 to 2 hours in the regular daily
schedule for counseling and activities.
b. Permit the intern to attend appropriate conferences.
c. Encourage in-service training activities and opportunities with professional staff.
d. Make provisions for facilities and materials to be used by the intern.
e. Support the opportunity for intern audio/visual taping of taping of selected
counseling sessions
f. Review and sign the intern's monthly time sheet.
Responsibilities of the Site Supervisor:
a. Provide the intern with an overall orientation to the agency's specific services
necessary for the implementation of the internship experience.
b. Provide professional assistance to the intern in attaining the internship objectives.
c. Attend, when possible, professional meetings and conferences with the intern.
d. Acquaint the intern with agency procedures dealing with crisis situations.
e. Assist the intern in attaining permission for taping selected counseling sessions
f. Make provisions for the intern to tape selected counseling sessions.
g. Review and sign the intern's monthly time sheet.
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h. Complete the evaluation form, in cooperation with the agency director, once per
semester.
Responsibilities of the Counselor Intern:
a. Secure the approval of the Community Agency Director to participate in the counselor
education internship.
b. Make arrangements with a qualified Community counselor to serve as your
sponsoring counselor or site supervisor.
c. Work cooperatively with the agency director, site supervisor, and the university
supervisor in planning the objectives and the means of attaining the objectives in the
internship experience.
d. Assist in making arrangements for the university supervisor to visit the agency and
meet with the site supervisor.
e. Attend conferences that are considered important by the site supervisor and the
university supervisor.
f. Affiliate with: The American Counseling Association (ACA), The Licensed
Professional Counselors Association of Georgia, American Mental Counselor
Association (AMHCA).
g. Prepare and submit to the university supervisor a monthly time sheet.
h. Take advantage of the many opportunities for professional improvement during the
internship experience.
i. Complete end of semester evaluations.
Responsibilities of the University Supervisor:
a. Assist the intern in planning for the internship experience.
b. Assist the intern and site supervisor in formulating the internship objectives.
c. Make periodic visits to the intern’s agency.
d. Work with the intern and the agency to make the internship experience as meaningful
and as purposeful as possible.
e. Assist the sponsoring counselor in providing support for the counselor intern.
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f. Assist each counselor intern in continually evaluating his/her progress in the
internship experience.
Acceptance
I agree to accept the above stated responsibilities involved in this internship experience.
_________________________________________ _________________
Agency Director Date
_________________________________________ _________________
Site Supervisor Date
_________________________________________ _________________
Counselor Intern Date
_________________________________________ _________________
University Supervisor Date
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STUDENT INTERNSHIP AGREEMENT
DIRECTIONS: Student is to complete this form in duplicate and submit a copy of this
agreement to the university supervisor.
A. I hereby attest that I have read and understand the American Counseling Association
ethical standards and will practice my counseling in accordance with these standards.
Any breach of these ethics or any unethical behavior on my part will result in my
removal from Internship and a failing grade, and documentation of such behavior
will become part of my permanent record.
B. I understand that my responsibilities include keeping my Internship supervisor(s)
informed regarding my Internship experience.
C. I agree to adhere to the administrative policies, rules, standards, practices of the
internship site.
D. I understand that I will note be issued a passing grade in Internship unless I
demonstrate the specified level of counseling skill, knowledge, competence and
complete the course requirements.
Signature _____________________________________
Date _________________________________________
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INTERNSHIP TIME SHEET
Directions:
1. Record the dates of each week.
2. Record the total number of hours per week for each activity under the appropriate column.
3. Total the number of hours for the week at the bottom of the week's column.
4. At the end of the month, total the hours spent in each activity by adding the hours across
each activity; indicate the total in the monthly columns.
5. Submit to site supervisor and director for signature.
6. Submit one copy to university supervisor each month and keep one copy for own records.
Activities Week I Week 2 Week 3 Week 4 Monthly
From: From: From: From: totals
To: To: To: To:
Orientation
Intake Interview
Individual
Counseling.
Group Counseling
Vocational/ career
counseling
Advocacy/
Networking
Professional
Development
Self-improvement
Testing
Administering
Interpret Tests
Use of Technology
Program
Coordination
Consultation/
Collaboration
Administration/
Staff
Team Processes
Site Supervision
Other
Weekly Totals
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Interns Name ________________________________________ Date
___________________________________
Site Supervisor's Signature _____________________________ Date
___________________________________
Director's Signature __________________________________ Date
___________________________________
Georgia Southern University
Counselor Education Program
Checklist for monthly activities
Activities:
Orientation to Internship Site:
Individual Counseling Sessions:
Personal/Social concerns, Academic concerns, Career concerns,
Group Counseling Sessions
Psychoeducational Group Sessions
Conflict management/peer facilitation
Consultations:
Other specialist, families, agencies
Testing:
Administration and interpretation
Community Activities:
Talks/presentations
Professional Self-improvement:
Attending staffing and treatment meetings, conferring with on-site counselor, conferring with
university supervisor, reading articles and books on guidance and counseling (may not exceed 25
hours for total internship)
Activities with Community Staff and Administration:
In-service/staff development sessions, faculty support group, create newsletter
Program Coordination:
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Collecting data and information, allocating materials and resources, scheduling and organizing
meetings, developing and operating special events and programs, paperwork
Other:
New student orientation, GCIS, Creating a website
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Georgia Southern University
Counselor Education Program
Site Evaluation Form
Directions: Student completes this form at the end of the Internship. This should be turned into
the university supervisor.
Name ____________________________________ Site _______________________________
Dates of Placement _________________________ Director ___________________________
Site Supervisor ________________________________________________________________
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. ____ Quality and usefulness of on-site supervision
3. ____ Usefulness and helpfulness of faculty supervisor
4. ____ Usefulness and helpfulness of group supervision
5. ____ Relevance of experience to career goals
6. ____ Exposure to and communication of agency’s goals
7. ____ Exposure to and communication of agency’s procedures
8. ____ Exposure to professional roles and functions within the agency
9. ____ Rate all applicable experiences that you had at your site
____ Intake interviewing
____ Administration and interpretation of tests
____ Individual Counseling
____ Group Counseling
____ Consultation
____ Career Counseling
____ Collaboration with staff and administration
____ Other
10. ____ Overall Evaluation of the site
11. ____ Overall Evaluation of on-site supervisor
Comments: Include any suggestions for improvements
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25
Georgia Southern University
INTERN PERFORMANCE EVALUATION
Student: ________________________________________ Date: ________________
Supervisor: ____________________________________________________________
Site: __________________________________________________________________
Semester: Fall Spring Intern’s final term at site? Yes No
Internship I: Internship II : Internship I and II:
The site supervisor should complete this form at the end of each semester. Circle the number to
the right of each item that best describes your perceptions of the intern’s skill compared to all
other people you have trained at the same level of professional development. If the current
evaluation if for the intern’s final term at the site, it should be treated as a summative evaluation.
(The term ―client‖ as used herein refers to any person receiving services including students,
parents, or teachers.)
IO = Inadequate Opportunity to Observe
NR = Not Relevant to the Setting
Counseling Skill Clearly Clearly Clearly
Deficient Adequate Excellent
Competency
1 2 3 4 5 IO NR
1. Establishes a working relationship with
1 2 3 4 5 IO NR
clients and gains client confidence.
2. Facilitates the client expression of
1 2 3 4 5 IO NR
concerns.
3. Establishes relevant counseling goals 1 2 3 4 5 IO NR
with client.
4. Implements an intervention strategy
1 2 3 4 5 IO NR
consistent with client information and
goals.
5. Evaluates client progress with respect 1 2 3 4 5 IO NR
to goals.
6. Facilitates the client’s resolution of
1 2 3 4 5 IO NR
concerns.
7. Appropriately refers and terminates
1 2 3 4 5 IO NR
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clients.
8. Understands theoretical principles as 1 2 3 4 5 IO NR
applied to particular client problems.
9. Understands diverse cultural, ethnic,
1 2 3 4 5 IO NR
sexual and social backgrounds and
values.
10. Demonstrates ethical behavior in the
1 2 3 4 5 IO NR
counseling activity and case
management.
Clearly Clearly Clearly
Supervision Competency Deficient Adequate Excellent
1 2 3 4 5 IO NR
1. Meets with supervisor as scheduled. 1 2 3 4 5 IO NR
2. Engages in open, comfortable and clear
communication with peers and 1 2 3 4 5 IO NR
supervisors.
3. Accepts and uses constructive feedback
to enhance self-development and 1 2 3 4 5 IO NR
counseling skills.
4. Uses supervision constructively. 1 2 3 4 5 IO NR
5. Open to growth and learning.
1 2 3 4 5 IO NR
Clearly Clearly Clearly
Case Management Skill Competency Deficient Adequate Excellent
1 2 3 4 5 IO NR
1. Knows community resources. 1 2 3 4 5 IO NR
2. Appropriately uses referrals within and
outside the site 1 2 3 4 5 IO NR
3. Responsibly schedules and meets with
1 2 3 4 5 IO NR
clients.
4. Keeps adequate and timely client
1 2 3 4 5 IO NR
records.
5. Consults with other staff regarding
1 2 3 4 5 IO NR
client needs.
6. Fulfills administrative responsibilities
1 2 3 4 5 IO NR
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of the position.
Clearly Clearly Clearly
Community Counseling Skill Deficient Adequate Excellent
Competency 1 2 3 4 5 IO NR
1. Demonstrates appropriate and effective
1 2 3 4 5 IO NR
treatment planning, assessment, and
diagnostic skills.
2. Demonstrates effective individual 1 2 3 4 5 IO NR
and group counseling skills.
3. Demonstrates appropriate 1 2 3 4 5 IO NR
advocacy skills.
4. Demonstrates an understanding 1 2 3 4 5 IO NR
of family systems.
5. Demonstrates an understanding 1 2 3 4 5 IO NR
of working with addictions.
Based on your experiences, what would you evaluate as being the student’s major strengths?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Suggestions for further professional development:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
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_________________________________________ __________________
Signature of Site Supervisor Date
_________________________________________ __________________
Signature of Faculty Supervisor Date
My signature indicates I have read and discussed the material above with my site and
faculty supervisors. It does not indicate my total or partial agreement with the evaluation.
_________________________________________ __________________
Signature of Intern Date
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30
INTERN EVALUATION OF SUPERVISOR*
Suggested Use: The practicum or internship supervisor can obtain feedback on the supervision
by asking student counselors to complete this form. The evaluation could be done at midterm
and/or final. The purposes are twofold: (1) to provide feedback for improving supervision and
(2) to encourage communication between the supervisor and the student counselor.
Directions: The student counselor is to evaluate the supervision received. Circle the number that
best represents how you, the student counselor, feel about the supervision received. After the
form is completed, the supervisor may suggest a meeting to discuss the supervision desired.
Name of practicum/Internship supervisor:
_________________________________________________
Period covered: from _______________________________ to _________________________
Poor Adequate Good
1. Gives time and energy in observations, tape processing, and 1 2 3 4 5 6
case conferences.
2. Accepts and respects me as a person. 1 2 3 4 5 6
3. Recognizes and encourages further development of my 1 2 3 4 5 6
strengths and capabilities.
4. Gives me useful feedback when 1 do something well. 1 2 3 4 5 6
5. Provides me the freedom to develop flexible and effective 1 2 3 4 5 6
counseling styles.
6. Encourages and listens to my ideas and suggestions for 1 2 3 4 5 6
developing my counseling skills.
7. Provides suggestions for developing my counseling skills. 1 2 3 4 5 6
8. Helps me understand the implications and dynamics of the 1 2 3 4 5 6
counseling approaches I use.
9. Encourages me to use new and different techniques when 1 2 3 4 5 6
appropriate.
10. Is spontaneous and flexible in the supervisory sessions. 1 2 3 4 5 6
11. Helps me define and achieve specific concrete goals for 1 2 3 4 5 6
myself during the practicum experience.
12. Gives me useful feedback when I do something wrong. 1 2 3 4 5 6
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13. Allows me to discuss problems I encounter in my practicum 1 2 3 4 5 6
setting.
14. Pays appropriate amount of attention to both me and my 1 2 3 4 5 6
clients.
15. Focuses on both verbal and nonverbal behavior in 1 2 3 4 5 6
me and in my clients
16. Helps me define and maintain ethical behavior in counseling 1 2 3 4 5 6
and case management.
17. Encourages me to engage in professional behavior. 1 2 3 4 5 6
18. Maintains confidentiality in material discussed 1 2 3 4 5 6
in supervisory sessions.
19. Deals with both content and effect when supervising. 1 2 3 4 5 6
20. Focuses on the implications, consequences, and 1 2 3 4 5 6
contingencies of
specific behaviors in counseling and supervision.
21. Helps me organize relevant case data in planning 1 2 3 4 5 6
goals and strategies with my client.
22. Helps me to formulate a theoretically sound rationale 1 2 3 4 5 6
of human behavior.
23. Offers resource information when I request or need it. 1 2 3 4 5 6
24. Helps me develop increased skill in critiquing and gaining 1 2 3 4 5 6
insight from my counseling tapes.
25. Allows and encourages me to evaluate myself. 1 2 3 4 5 6
26. Explains his/her criteria for evaluation clearly and in 1 2 3 4 5 6
behavioral terms.
27. Applies his/her criteria fairly in evaluating my counseling 1 2 3 4 5 6
performance.
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ADDITIONAL COMMENTS AND/OR SUGGESTIONS
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Date Signature of practicum student/intern
My signature indicates that I have read the above report and have discussed the content with my
supervisee. It does not necessarily indicate that I agree with the report in part or in whole.
Date Signature of supervisor
Form 12.4, p. 2 of 2
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ANALYSIS OF COUNSELING SESSION
Intern's Name: __________________________ Date of Interview ________________________
Client's Code Name: __________________________ Age ____________ Sex _____________
Number of interviews with client: ____________
Brief Summary of session content:
Intended goals:
Observations about client's behaviors/dynamics:
Comments on positive counseling behaviors/techniques:
Comment on areas of counseling practice that need improvement
Plans for further counseling:
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CLIENT RELEASE FORM
Georgia Southern University
Counselor Education Program
I ___________________________________________________, agree to be counseled by an intern
student in the Counselor Education Program at Georgia Southern University.
I further, understand that I will participate in counseling interviews that will be audio-taped,
videotaped, and viewed by intern students.
I understand that I will be counseled by a graduate student who has completed advanced
coursework in counseling/therapy.
I understand that the intern will be supervised by a faculty member and/or a site supervisor.
Client's signature ______________________________________________________________
Age _____________________________ Date _______________________________________
Counselor's signature ___________________________________________________________
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CC Site Supervisor Manual
35
PARENTAL RELEASE FORM
Parent's Name
_________________________________________________________________
Address
_____________________________________________________________________
Phone ______________________ (Home) ______________________ (Work)
The Graduate Department of Counselor Education at Georgia Southern University
conducts a Counseling Internship Course each semester at the university. The Internship
course is an advanced course in counseling required of all candidates in the Counseling
Program at Georgia Southern University. Students are required to audio-and/or videotape
counseling sessions as part of their course and degree requirements.
Intern's name ______________________________________________ would like to
work with your son/daughter, a student at
_____________________________________Community.
The counseling sessions conducted with your child will be audio-and/or videotaped and
will be reviewed by the intern's supervisor ____________________________. All
audio-and videotapes made will be erased at the completion of your child's involvement
in the program.
We hope that you will take the opportunity to have your child become involved in the
Counseling Program. If you are interested in having your child participate, please sign the
form where indicated.
Thank you for your cooperation.
Parent's Signature
___________________________________________
Date
__________________________________________________
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CC Site Supervisor Manual
36
We appreciate your willingness to give your professional time and expertise during this process.
If you need further information or have concerns or recommendations please contact; Dr Leon E.
Spencer, Coordinator Community Counseling Program at (912) 681-5917 or
lespence@georgiasouthern.edu
Name ____________________________________ Site _______________________________
Dates of Placement _________________________ Director ___________________________
Site Evaluation Form
Site Supervisor ________________________________________________________________
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
Directions: Student completes this
1. ____ Amount of on-site supervision form at the end of the Internship. This
2. ____ Quality and usefulness of on-site supervision should be turned into
3. ____ Usefulness and helpfulness of faculty supervisor the university
4. ____ Usefulness and helpfulness of group supervision supervisor.
5. ____ Relevance of experience to career goals
6. ____ Exposure to and communication of school goals
7. ____ Exposure to and communication of school procedures
8. ____ Exposure to professional roles and functions within the school
9. ____ Rate all applicable experiences that you had at your site
____ Intake interviewing
____ Administration and interpretation of tests
____ Individual Counseling
____ Group Counseling
____ Consultation
____ Career Counseling
____ Collaboration with faculty and administration
____ Other
10. ____ Overall Evaluation of the site
11. ____ Overall Evaluation of on-site supervisor
Comments: Include any suggestions for improvements
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
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CC Site Supervisor Manual
37
INTERN EVALUATION OF SUPERVISOR*
Suggested Use: The internship supervisor can obtain feedback on the supervision by
asking counselors-in-training to complete this form. The evaluation could be done at
midterm and/or final. The purposes are twofold: (1) to provide feedback for improving
supervision and (2) to encourage communication between the supervisor and the
counselor-in-training.
Directions: The counselor-in-training is to evaluate the supervision received. Circle the
number that best represents how you, the counselor-in-training, feels about the supervision
received. After the form is completed, the supervisor may suggest a meeting to discuss the
supervision desired.
Name of Practicum/Internship supervisor: ___________________________________
Period covered: from _________________________ to _________________________
Poor Adequate Good
1. Gives time and energy in observations, tape processing, and 12 3 4 5 6
case conferences.
2. Accepts and respects me as a person. 1 2 3 4 5 6
3. Recognizes and encourages further development of my 1 2 3 4 5 6
strengths and capabilities.
4. Gives me useful feedback when 1 do something well. 1 2 3 4 5 6
5. Provides me the freedom to develop flexible and effective 1 2 3 4 5 6
counseling styles.
6. Encourages and listens to my ideas and suggestions for 1 2 3 4 5 6
developing my counseling skills.
7. Provides suggestions for developing my counseling skills. 1 2 3 4 5 6
8. Helps me understand the implications and dynamics of the 1 2 3 4 5 6
counseling approaches I use.
9. Encourages me to use new and different techniques when 12 3 4 5 6
appropriate.
10. Is spontaneous and flexible in the supervisory sessions. 1 2 3 4 5 6
11. Helps me define and achieve specific concrete goals for 1 2 3 4 5 6
myself during the practicum experience.
12. Gives me useful feedback when I do something wrong. 1 2 3 4 5 6
13. Allows me to discuss problems I encounter in my practicum 1 2 3 4 5 6
setting.
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14. Pays appropriate amount of attention to both me and my clients. 1 2 3 4 5 6
15. Focuses on both verbal and nonverbal behavior in me and. 1 2 3 4 5 6
in my clients
16. Helps me define and maintain ethical behavior in counseling 1 2 3 4 5 6
and case management.
17. Encourages me to engage in professional behavior. 1 2 3 4 5 6
18. Maintains confidentiality in material discussed in supervisory 1 2 3 4 5 6
sessions.
19. Deals with both content and effect when supervising. 1 2 3 4 5 6
20. Focuses on the implications, consequences, and contingencies of 1 2 3 4 5 6
specific behaviors in counseling and
supervision.
21. Helps me organize relevant case data in planning goals and 1 2 3 4 5 6
strategies with my client.
22. Helps me to formulate a theoretically sound rationale of 1 2 3 4 5 6
human behavior.
23. Offers resource information when I request or need it. 1 2 3 4 5 6
24. Helps me develop increased skill in critiquing and gaining 1 2 3 4 5 6
insight from my counseling tapes.
25. Allows and encourages me to evaluate myself. 1 2 3 4 5 6
26. Explains his/her criteria for evaluation clearly and in 1 2 3 4 5 6
behavioral terms.
27. Applies his/her criteria fairly in evaluating my counseling 1 2 3 4 5 6
performance.
ADDITIONAL COMMENTS AND/OR SUGGESTIONS
_________ _______________________________________________
Date Signature of intern
My signature indicates that I have read the above report and have discussed the content
with my supervisee. It does not necessarily indicate that I agree with the report in part or
in whole.
________ _______________________________________________
Date Signature of supervisor
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CC Site Supervisor Manual
39
2) Group Dynamics
3) Addiction Counseling
4) Theories of Counseling
5) Family Counseling
6) Models/Techniques of Counseling
7) Counseling Assessment, Diagnosis &
Intervention
8) Practicum in Counseling
9) Career Counseling
10) Counseling Internship
11) Cross Cultural Counseling
12) Counseling Internship
13) Life Span Development
14) Learning Theories & Applications
15) Individual Analysis
16) Educational Research
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CC Site Supervisor Manual
40
Revised August, 2008
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