Collection of practicum and internship evaluation forms.

1. For use by Training Department Only
CR NC I
1
PSYD INTERNSHIP EVALUATION FORM
ARGOSY UNIVERSITY/DALLAS –COLLEGE OF PSYCHOLOGY AND BEHAVIORAL SCIENCES
Student Name:
Internship Site Name: Site Director
Primary Site Supervisor: Site Address:
Secondary Site Supervisor: City, State, Zip: ,
Semester: Phone:
Dates
Evaluated
From: To: Internship Term: Fall Internship
The doctoral program in clinical psychology at Argosy University aspires to train students to be proficient in the National Council of Schools
of Professional Psychology (NCSPP) competencies. The internship placements help develop and evaluate the student’s competency in
relationships, diversity, assessment, and intervention. The primary internship supervisor completes this form at the end of each semester of the
internship (e.g., December and August). This form documents the students progress toward expected levels of proficiency The primary
supervisor is encouraged to email (AUDClinicalTraining@argosyu.edu) this form without a signature or may
alternately fax this form (214) 459-2225 with a signature to the Director of Clinical Training.
The primary supervisor should assess proficiency in the specific competency listed below based on this scale keeping
two things in mind: (a) the student’s demonstrated proficiency in the competency area and (b) the expected proficiency
noted on this rating form.
3 Proficient:  Perceives situations as wholes rather than component parts
 Learns from their practice what characteristic events to expect in a given situation
 Plans for the need to modify responses to changes in situations
2 Intermediate:  Recognizes important recurring and meaningful situational components
 Ability generalize diagnostic and intervention skills to new situations is limited
 Support is needed to guide performance
1 Novice:  Limited knowledge and perception of how to analyze problems and of interventions
 Limited knowledge of how processes and techniques are implemented
 Knowledge of general principles or specific techniques to use but limited experience
restricts the flexibility of using these skills.
 Trouble differentiating between important and unimportant details
0 Deficient  Insufficient knowledge or skill
 Inappropriate and/or inflexible attitude
N/A Not Applicable:  Insufficient data; no opportunity to demonstrate; not observed
RELATIONSHIP (INTERPERSONAL)
Work effectively with clients, colleagues, supervisors, and others in professional settings. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of impact of self on others. 2
Shows respect for clients. 2
Can establish an effective working alliance with clients 2
Accurately understands client communications. 2
Demonstrates appropriate professional presentation of self. 2
Effectively manages responsibilities. 2
Shows respect for colleagues from other theoretical
orientations and professional disciplines.
2
Conforms to agency expectations in scheduling, absences,
submittal of reports, and other aspects of conducting business.
2

2. 2
Revision 08/06
Prepares for supervision (e.g., brings relevant material for
discussion).
2
Approaches supervision in an open and collaborative manner. 2
Incorporates supervisor’s feedback into professional work. 2
Seeks out extra supervision when necessary. 2
Apply ethical principles of clinical psychology and relevant law to the practice of clinical psychology. To this end,
student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Behaves in accordance with the APA Code of Ethics and Texas
state law.
2
Shows knowledge of and ability to employ ethical standards in
professional relations.
2
Follows ethical guidelines regarding the use and dissemination
of private and confidential information.
2
Can complete a thoughtful and informed ethical decision-
making procedure.
2
Overall Proficiency Expected Demonstrated
Relationship Competency 2
Please provide specific examples of behavior that lead to the above proficiency ratings.
DIVERSITY
Students will form and maintain professional relationships as service providers, colleagues, and leaders with individuals
with diverse identities and backgrounds (e.g., race, ethnicity, sexual identity, gender, age, socioeconomic status, religion)..
To this end, the student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of own diversity issues and willing to self-reflect on
issues of diversity.
2
Demonstrates knowledge of diversity issues consistent with
APA guidelines on multicultural issues related to practice with
clients of diverse backgrounds
2
Can provide interventions appropriate to people of diverse
populations
2
Overall Proficiency Expected Demonstrated
Diversity Competency 2
Please provide specific examples of behavior that lead to the above proficiency ratings.

3. 3
Revision 08/06
ASSESSMENT
Conduct psychological assessments. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can assess potential dangerousness of client’s behavior to self
and others.
2
Can formulate an initial treatment plan based on
diagnostic/intake interview
2
Demonstrates knowledge of psychometric principles and
limitations of assessment instruments.
2
Can select, administer, interpret, and synthesize results from
intelligence, personality and other instruments.
2
Please list tests:
Can integrate test data with clinical observations and make a
multiaxial diagnosis.
2
Can evaluate cultural and diversity influences intelligence,
personality, and other psychological measures.
2
Write clear, grammatical, well-organized, and well-reasoned professional reports and papers. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can write grammatically correct, clear, and concise reports in a
language appropriate to the report’s referral source. (e.g.,
psychologist, attorney, patient)
2
Can summarize and integrate test data (e.g., cognitive,
neuropsychological, personality) into a well-written report.
2
Can write clear concise case reports, treatment plans, and
progress notes.
2
Overall Proficiency Expected Demonstrated
Assessment Competency 2
Please provide specific examples of behavior that lead to the above proficiency ratings.
INTERVENTION
Apply theories of psychotherapy and psychotherapy research to work with clients. To this end, the student:
Primary theoretical orientation practiced at internship:
KSA Expected
Proficiency
Demonstrated
Proficiency
Understands key theoretical concepts of orientation noted
above.
2
Can apply key concepts of orientation noted above to
treatment planning with diverse client populations.
2
Can apply key concepts of orientation noted above to
conceptualizing course of psychotherapy with diverse client
populations.
2

4. 4
Revision 08/06
Employ psychotherapy interventions consistent with above noted orientation with clients. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Demonstrates competency in using orientation noted above: 2
Understands complexity of client problems. 2
Can assist clients in setting realistic treatment goals. 2
Can identify, carry out, and evaluate the quality and
effectiveness of therapeutic interventions.
2
Can adjust interventions according to phases and stages of
relationships and therapeutic settings.
2
Overall Proficiency Expected Demonstrated
Intervention Competency 2
Please provide specific examples of behavior that lead to the above proficiency ratings.
OVERALL EVALUATION
Please describe the student’s strengths as a graduate student in clinical psychology.
Please describe aspects of the student’s work as a potential clinical psychologist that might benefit from additional supervision or
mentoring.
Do any of the above areas needing additional supervision or mentoring need to be referred to the Clinical Training
Committee? (Check one:) No Yes
If Yes, please explain:
Email to AUDClinicalTraining@argosyu.edu
Supervisor’s Signature Date Student’s Signature Date
License Type: ; Number:
Received by Training Department Date

5. For use by Training Department Only
CR NC I
1
PSYD INTERNSHIP EVALUATION FORM
ARGOSY UNIVERSITY/DALLAS –COLLEGE OF PSYCHOLOGY AND BEHAVIORAL SCIENCES
Student Name:
Internship Site Name: Site Director
Primary Site Supervisor: Site Address:
Secondary Site Supervisor: City, State, Zip: ,
Semester: Phone:
Dates
Evaluated
From: To: Internship Term: Spring Internship
The doctoral program in clinical psychology at Argosy University aspires to train students to be proficient in the National Council of Schools
of Professional Psychology (NCSPP) competencies. The internship placements help develop and evaluate the student’s competency in
relationships, diversity, assessment, and intervention. The primary internship supervisor completes this form at the end of each semester of the
internship (e.g., December and August). This form documents the students progress toward expected levels of proficiency The primary
supervisor is encouraged to email (AUDClinicalTraining@argosyu.edu) this form without a signature or may
alternately fax this form (214) 459-2225 with a signature to the Director of Clinical Training.
The primary supervisor should assess proficiency in the specific competency listed below based on this scale keeping
two things in mind: (a) the student’s demonstrated proficiency in the competency area and (b) the expected proficiency
noted on this rating form.
3 Proficient:  Perceives situations as wholes rather than component parts
 Learns from their practice what characteristic events to expect in a given situation
 Plans for the need to modify responses to changes in situations
2 Intermediate:  Recognizes important recurring and meaningful situational components
 Ability generalize diagnostic and intervention skills to new situations is limited
 Support is needed to guide performance
1 Novice:  Limited knowledge and perception of how to analyze problems and of interventions
 Limited knowledge of how processes and techniques are implemented
 Knowledge of general principles or specific techniques to use but limited experience
restricts the flexibility of using these skills.
 Trouble differentiating between important and unimportant details
0 Deficient  Insufficient knowledge or skill
 Inappropriate and/or inflexible attitude
N/A Not Applicable:  Insufficient data; no opportunity to demonstrate; not observed
RELATIONSHIP (INTERPERSONAL)
Work effectively with clients, colleagues, supervisors, and others in professional settings. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of impact of self on others. 3
Shows respect for clients. 3
Can establish an effective working alliance with clients 3
Accurately understands client communications. 3
Demonstrates appropriate professional presentation of self. 3
Effectively manages responsibilities. 3
Shows respect for colleagues from other theoretical
orientations and professional disciplines.
3
Conforms to agency expectations in scheduling, absences,
submittal of reports, and other aspects of conducting business.
3

6. 2
Revision 08/06
Prepares for supervision (e.g., brings relevant material for
discussion).
3
Approaches supervision in an open and collaborative manner. 3
Incorporates supervisor’s feedback into professional work. 3
Seeks out extra supervision when necessary. 3
Apply ethical principles of clinical psychology and relevant law to the practice of clinical psychology. To this end,
student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Behaves in accordance with the APA Code of Ethics and Texas
state law.
3
Shows knowledge of and ability to employ ethical standards in
professional relations.
3
Follows ethical guidelines regarding the use and dissemination
of private and confidential information.
3
Can complete a thoughtful and informed ethical decision-
making procedure.
3
Overall Proficiency Expected Demonstrated
Relationship Competency 3
Please provide specific examples of behavior that lead to the above proficiency ratings.
DIVERSITY
Students will form and maintain professional relationships as service providers, colleagues, and leaders with individuals
with diverse identities and backgrounds (e.g., race, ethnicity, sexual identity, gender, age, socioeconomic status, religion)..
To this end, the student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of own diversity issues and willing to self-reflect on
issues of diversity.
3
Demonstrates knowledge of diversity issues consistent with
APA guidelines on multicultural issues related to practice with
clients of diverse backgrounds
3
Can provide interventions appropriate to people of diverse
populations
3
Overall Proficiency Expected Demonstrated
Diversity Competency 3
Please provide specific examples of behavior that lead to the above proficiency ratings.

7. 3
Revision 08/06
ASSESSMENT
Conduct psychological assessments. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can assess potential dangerousness of client’s behavior to self
and others.
3
Can formulate an initial treatment plan based on
diagnostic/intake interview
3
Demonstrates knowledge of psychometric principles and
limitations of assessment instruments.
3
Can select, administer, interpret, and synthesize results from
intelligence, personality and other instruments.
3
Please list tests:
Can integrate test data with clinical observations and make a
multiaxial diagnosis.
3
Can evaluate cultural and diversity influences intelligence,
personality, and other psychological measures.
3
Write clear, grammatical, well-organized, and well-reasoned professional reports and papers. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can write grammatically correct, clear, and concise reports in a
language appropriate to the report’s referral source. (e.g.,
psychologist, attorney, patient)
3
Can summarize and integrate test data (e.g., cognitive,
neuropsychological, personality) into a well-written report.
3
Can write clear concise case reports, treatment plans, and
progress notes.
3
Overall Proficiency Expected Demonstrated
Assessment Competency 3
Please provide specific examples of behavior that lead to the above proficiency ratings.
INTERVENTION
Apply theories of psychotherapy and psychotherapy research to work with clients. To this end, the student:
Primary theoretical orientation practiced at internship:
KSA Expected
Proficiency
Demonstrated
Proficiency
Understands key theoretical concepts of orientation noted
above.
3
Can apply key concepts of orientation noted above to
treatment planning with diverse client populations.
3
Can apply key concepts of orientation noted above to
conceptualizing course of psychotherapy with diverse client
populations.
3
Employ psychotherapy interventions consistent with above noted orientation with clients. To this end, student:

8. 4
Revision 08/06
KSA Expected
Proficiency
Demonstrated
Proficiency
Demonstrates competency in using orientation noted above: 3
Understands complexity of client problems. 3
Can assist clients in setting realistic treatment goals. 3
Can identify, carry out, and evaluate the quality and
effectiveness of therapeutic interventions.
3
Can adjust interventions according to phases and stages of
relationships and therapeutic settings.
3
Overall Proficiency Expected Demonstrated
Intervention Competency 3
Please provide specific examples of behavior that lead to the above proficiency ratings.
OVERALL EVALUATION
Please describe the student’s strengths as a graduate student in clinical psychology.
Please describe aspects of the student’s work as a potential clinical psychologist that might benefit from additional supervision or
mentoring.
Do any of the above areas needing additional supervision or mentoring need to be referred to the Clinical Training
Committee? (Check one:) No Yes
If Yes, please explain:
Email to AUDClinicalTraining@argosyu.edu
Supervisor’s Signature Date Student’s Signature Date
License Type: ; Number:
Received by Training Department Date

9. For use by Training Department Only
CR NC I
1 Revised 08/06
PSYD PRACTICUM EVALUATION FORM
ARGOSY UNIVERSITY/DALLAS –COLLEGE OF PSYCHOLOGY AND BEHAVIORAL SCIENCES
Student Name: Practicum Site Name:
Site Director: Site Director Email:
Primary Site Supervisor: Primary Supervisor Email:
Secondary Site Supervisor: Secondary Site Email:
Semester: Site Phone:
Dates
Evaluated
From: To: Practicum Type: PsyD I
The doctoral program in clinical psychology at Argosy University aspires to train students within a Practitioner-Scholar Model to be proficient
in the National Council of Schools of Professional Psychology (NCSPP) competencies. The practicum placements help develop and evaluate
the student’s competency in relationships, diversity, assessment, and intervention. The primary practicum supervisor completes this form at the
end of each semester of the practicum (e.g., December, May, August). This form documents the students progress toward expected levels of
proficiency The primary supervisor is encouraged to email (AUDClinicalTraining@argosyu.edu) this form
without a signature or may alternately fax this form with a signature to the Director of Clinical Training (214)
459-2225.
The primary supervisor should assess proficiency in the specific competency listed below based on this scale keeping
two things in mind: (a) the student’s demonstrated proficiency in the competency area and (b) the expected proficiency
noted on this rating form.
3 Proficient:  Perceives situations as wholes rather than component parts
 Learns from their practice what typical things to expect in a given situation
 Plans for the need to modify responses to changes in situations
2 Intermediate:  Brings growing knowledge base to bear on interventions
 Ability to generalize skills to new situations is still limited
 Support is needed to guide performance
1 Novice:  Limited knowledge and perception of how to intervene or assess
 Limited awareness of self
 Knowledge of general principles or specific techniques to use but limited experience
restricts the flexibility of using these skills
 Trouble differentiating between important and unimportant details
0 Deficient  Insufficient knowledge or skill
 Inappropriate and/or inflexible attitude
N/A Not Applicable:  Insufficient data; no opportunity to demonstrate; not observed
RELATIONSHIP (INTERPERSONAL)
Students will develop and maintain effective ethical and professional therapeutic relationships. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of impact of self on others. 1
Shows respect for clients. 1
Can establish an effective working alliance with clients 1
Accurately understands client communications. 1
Demonstrates appropriate professional presentation of self. 1
Effectively manages responsibilities. 1
Shows respect for colleagues from other theoretical
orientations and professional disciplines.
1
Conforms to agency expectations in scheduling, absences, 1

10. PsyD I Practicum Evaluation 2
Revised 08/06
submittal of reports, and other aspects of conducting business.
Prepares for supervision (e.g., brings relevant material for
discussion).
1
Approaches supervision in an open and collaborative manner. 1
Incorporates supervisor’s feedback into professional work. 1
Seeks out extra supervision when necessary. 1
Apply ethical principles of clinical psychology and relevant law to the practice of clinical psychology. To this end,
student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Behaves in accordance with the APA Code of Ethics and Texas
state law.
1
Shows knowledge of and ability to employ ethical standards in
professional relations.
1
Follows ethical guidelines regarding the use and dissemination
of private and confidential information.
1
Can complete a thoughtful and informed ethical decision-
making procedure.
1
Overall Proficiency Expected Demonstrated
Relationship Competency 1
Please provide specific examples of behavior that led to the above proficiency ratings.
DIVERSITY
Students will competently conceptualize and deliver diagnostic and therapeutic services by demonstrating: (a) awareness
of how own cultural background mediates interventions, (b) knowledge of multicultural concepts that are likely to affect
interventions, and (c) skills in providing effective interventions. To this end, the student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of own diversity issues and willing to self-reflect on
issues of diversity.
1
Demonstrates knowledge consistent with APA guidelines on
multicultural issues related to practice with clients of diverse
backgrounds.
1
Demonstrates sensitivity to influence of culture, ethnicity,
nationality, gender, sexual orientation, physical challenge,
religion, age, and other aspects of human diversity on the
interactions in therapeutic and professional relationships.
1
Can work effectively with diverse populations. 1
Overall Proficiency Expected Demonstrated
Diversity Competency 1
Please provide specific examples of behavior that led to the above proficiency ratings.

11. PsyD I Practicum Evaluation 3
Revised 08/06
ASSESSMENT
Students will deliver assessment and diagnostic services in a manner consistent with professional and ethical standards
by effectively assessing and conceptualizing the strengths and problems of clients through a variety of appropriate
assessment techniques and accurately communicating findings in a professional manner. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can assess potential dangerousness of client’s behavior to self
and others.
1
Can formulate an initial treatment plan based on
diagnostic/intake interview.
1
Demonstrates knowledge of psychometric principles and
limitations of assessment instruments.
1
Can select, administer, interpret, and synthesize results from
intelligence, personality and other instruments.
1
Please list tests:
Can integrate test data with clinical observations and make a
multiaxial diagnosis.
1
Can evaluate cultural and diversity influences intelligence,
personality, and other psychological measures.
1
Write clear, grammatical, well-organized, and well-reasoned professional reports and papers. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can write grammatically correct, clear, and concise reports in a
language appropriate to the report’s referral source. (e.g.,
psychologist, attorney, patient)
1
Can summarize and integrate test data (e.g., cognitive,
neuropsychological, personality) into a well-written report.
1
Can write clear concise case reports, treatment plans, and
progress notes.
1
Overall Proficiency Expected Demonstrated
Assessment Competency 1
Please provide specific examples of behavior that led to the above proficiency ratings.
INTERVENTION
Students will demonstrate competent interventions consistent with current ethical, scientific, and professional standards
that are (a) delivered from a specific theoretical and methodological orientation and (b) evaluated for effectiveness. To
this end, the student:
Primary theoretical orientation practiced at practicum:
KSA Expected
Proficiency
Demonstrated
Proficiency
Understands key theoretical concepts of orientation noted
above.
1
Can apply key concepts of orientation noted above to
treatment planning with clients.
1

12. PsyD I Practicum Evaluation 4
Revised 08/06
Can apply key concepts of orientation noted above to
conceptualizing course of psychotherapy with clients.
1
Employ psychotherapy interventions consistent with above noted orientation with clients. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Demonstrates competency in using orientation noted above: 1
Understands complexity of client problems. 1
Can assist clients in setting realistic treatment goals. 1
Can identify, carry out, and evaluate the quality and
effectiveness of therapeutic interventions.
1
Can adjust interventions according to phases and stages of
relationships and therapeutic settings.
1
Overall Proficiency Expected Demonstrated
Intervention Competency 1
Please provide specific examples of behavior that led to the above proficiency ratings.
OVERALL EVALUATION
Please describe the student’s strengths as a graduate student in clinical psychology.
Please describe aspects of the student’s work as a potential clinical psychologist that might benefit from additional supervision or
mentoring.
Do any of the above areas needing additional supervision or mentoring need to be referred to the Clinical Training
Committee? (Check one:) No Yes
If Yes, please explain:
Email to AUDClinicalTraining@argosyu.edu
Supervisor’s Signature Date Student’s Signature Date
License Type: ; Number:
Received by Training Department Date

13. PsyD I Practicum Evaluation 5
Revised 08/06

14. For use by Training Department Only
CR NC I
1 Revised 08/06
PSYD PRACTICUM EVALUATION FORM
ARGOSY UNIVERSITY/DALLAS –COLLEGE OF PSYCHOLOGY AND BEHAVIORAL SCIENCES
Student Name: Practicum Site Name:
Site Director: Site Director Email:
Primary Site Supervisor: Primary Supervisor Email:
Secondary Site Supervisor: Secondary Site Email:
Semester: Site Phone:
Dates
Evaluated
From: To: Practicum Type: PsyD II
The doctoral program in clinical psychology at Argosy University aspires to train students within a Practitioner-Scholar Model to be proficient
in the National Council of Schools of Professional Psychology (NCSPP) competencies. The practicum placements help develop and evaluate
the student’s competency in relationships, diversity, assessment, and intervention. The primary practicum supervisor completes this form at the
end of each semester of the practicum (e.g., December, May, August). This form documents the students progress toward expected levels of
proficiency The primary supervisor is encouraged to email (AUDClinicalTraining@argosyu.edu) this form
without a signature or may alternately fax this form with a signature to the Director of Clinical Training (214)
459-2225.
The primary supervisor should assess proficiency in the specific competency listed below based on this scale keeping
two things in mind: (a) the student’s demonstrated proficiency in the competency area and (b) the expected proficiency
noted on this rating form.
3 Proficient:  Perceives situations as wholes rather than component parts
 Learns from their practice what typical things to expect in a given situation
 Plans for the need to modify responses to changes in situations
2 Intermediate:  Brings growing knowledge base to bear on interventions
 Ability to generalize skills to new situations is still limited
 Support is needed to guide performance
1 Novice:  Limited knowledge and perception of how to intervene or assess
 Limited awareness of self
 Knowledge of general principles or specific techniques to use but limited experience
restricts the flexibility of using these skills
 Trouble differentiating between important and unimportant details
0 Deficient  Insufficient knowledge or skill
 Inappropriate and/or inflexible attitude
N/A Not Applicable:  Insufficient data; no opportunity to demonstrate; not observed
RELATIONSHIP (INTERPERSONAL)
Students will develop and maintain effective ethical and professional therapeutic relationships. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of impact of self on others. 2
Shows respect for clients. 3
Can establish an effective working alliance with clients 2
Accurately understands client communications. 3
Demonstrates appropriate professional presentation of self. 3
Effectively manages responsibilities. 3
Shows respect for colleagues from other theoretical
orientations and professional disciplines.
3
Conforms to agency expectations in scheduling, absences, 4

15. PsyD II Practicum Evaluation 2
Revised 08/06
submittal of reports, and other aspects of conducting business.
Prepares for supervision (e.g., brings relevant material for
discussion).
3
Approaches supervision in an open and collaborative manner. 3
Incorporates supervisor’s feedback into professional work. 2
Seeks out extra supervision when necessary. 3
Apply ethical principles of clinical psychology and relevant law to the practice of clinical psychology. To this end,
student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Behaves in accordance with the APA Code of Ethics and Texas
state law.
3
Shows knowledge of and ability to employ ethical standards in
professional relations.
3
Follows ethical guidelines regarding the use and dissemination
of private and confidential information.
3
Can complete a thoughtful and informed ethical decision-
making procedure.
3
Overall Proficiency Expected Demonstrated
Relationship Competency 3
Please provide specific examples of behavior that led to the above proficiency ratings.
DIVERSITY
Students will competently conceptualize and deliver diagnostic and therapeutic services by demonstrating: (a) awareness
of how own cultural background mediates interventions, (b) knowledge of multicultural concepts that are likely to affect
interventions, and (c) skills in providing effective interventions. To this end, the student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of own diversity issues and willing to self-reflect on
issues of diversity.
2
Demonstrates knowledge of diversity issues consistent with
APA guidelines on multicultural issues related to practice with
clients of diverse backgrounds
2
Can provide interventions appropriate to people of diverse
populations
2
Overall Proficiency Expected Demonstrated
Diversity Competency 2
Please provide specific examples of behavior that led to the above proficiency ratings.

16. PsyD II Practicum Evaluation 3
Revised 08/06
ASSESSMENT
Students will deliver assessment and diagnostic services in a manner consistent with professional and ethical standards
by effectively assessing and conceptualizing the strengths and problems of clients through a variety of appropriate
assessment techniques and accurately communicating findings in a professional manner. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can assess potential dangerousness of client’s behavior to self
and others.
3
Can formulate an initial treatment plan based on
diagnostic/intake interview
2
Demonstrates knowledge of psychometric principles and
limitations of assessment instruments.
2
Can select, administer, interpret, and synthesize results from
intelligence, personality and other instruments.
2
Please list tests:
Can integrate test data with clinical observations and make a
multiaxial diagnosis.
2
Can evaluate cultural and diversity influences intelligence,
personality, and other psychological measures.
2
Write clear, grammatical, well-organized, and well-reasoned professional reports and papers. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can write grammatically correct, clear, and concise reports in a
language appropriate to the report’s referral source. (e.g.,
psychologist, attorney, patient)
2
Can summarize and integrate test data (e.g., cognitive,
neuropsychological, personality) into a well-written report.
2
Can write clear concise case reports, treatment plans, and
progress notes.
2
Overall Proficiency Expected Demonstrated
Assessment Competency 2
Please provide specific examples of behavior that led to the above proficiency ratings.
INTERVENTION
Students will demonstrate competent interventions consistent with current ethical, scientific, and professional standards
that are (a) delivered from a specific theoretical and methodological orientation and (b) evaluated for effectiveness. To
this end, the student:
Primary theoretical orientation practiced at practicum:
KSA Expected
Proficiency
Demonstrated
Proficiency
Understands key theoretical concepts of orientation noted
above.
2

17. PsyD II Practicum Evaluation 4
Revised 08/06
Can apply key concepts of orientation noted above to
treatment planning with clients.
2
Can apply key concepts of orientation noted above to
conceptualizing course of psychotherapy with clients.
2
Employ psychotherapy interventions consistent with above noted orientation with clients. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Demonstrates competency in using orientation noted above: 2
Understands complexity of client problems. 2
Can assist clients in setting realistic treatment goals. 2
Can identify, carry out, and evaluate the quality and
effectiveness of therapeutic interventions.
2
Can adjust interventions according to phases and stages of
relationships and therapeutic settings.
2
Overall Proficiency Expected Demonstrated
Intervention Competency 2
Please provide specific examples of behavior that led to the above proficiency ratings.
OVERALL EVALUATION
Please describe the student’s strengths as a graduate student in clinical psychology.
Please describe aspects of the student’s work as a potential clinical psychologist that might benefit from additional supervision or
mentoring.
Do any of the above areas needing additional supervision or mentoring need to be referred to the Clinical Training
Committee? (Check one:) No Yes
If Yes, please explain:
Email to AUDClinicalTraining@argosyu.edu
Supervisor’s Signature Date Student’s Signature Date
License Type: ; Number:
Received by Training Department Date

18. PsyD II Practicum Evaluation 5
Revised 08/06

19. For use by Training Department Only
CR NC I
1 Revised 08/06
PSYD PRACTICUM EVALUATION FORM
ARGOSY UNIVERSITY/DALLAS –COLLEGE OF PSYCHOLOGY AND BEHAVIORAL SCIENCES
Student Name: Practicum Site Name:
Site Director: Site Director Email:
Primary Site Supervisor: Primary Supervisor Email:
Secondary Site Supervisor: Secondary Site Email:
Semester: Site Phone:
Dates
Evaluated
From: To: Practicum Type: PsyD III
The doctoral program in clinical psychology at Argosy University aspires to train students within a Practitioner-Scholar Model to be proficient
in the National Council of Schools of Professional Psychology (NCSPP) competencies. The practicum placements help develop and evaluate
the student’s competency in relationships, diversity, assessment, and intervention. The primary practicum supervisor completes this form at the
end of each semester of the practicum (e.g., December, May, August). This form documents the students progress toward expected levels of
proficiency The primary supervisor is encouraged to email (AUDClinicalTraining@argosyu.edu) this form
without a signature or may alternately fax this form with a signature to the Director of Clinical Training (214)
459-2225.
The primary supervisor should assess proficiency in the specific competency listed below based on this scale keeping
two things in mind: (a) the student’s demonstrated proficiency in the competency area and (b) the expected proficiency
noted on this rating form.
3 Proficient:  Perceives situations as wholes rather than component parts
 Learns from their practice what typical things to expect in a given situation
 Plans for the need to modify responses to changes in situations
2 Intermediate:  Brings growing knowledge base to bear on interventions
 Ability to generalize skills to new situations is still limited
 Support is needed to guide performance
1 Novice:  Limited knowledge and perception of how to intervene or assess
 Limited awareness of self
 Knowledge of general principles or specific techniques to use but limited experience
restricts the flexibility of using these skills
 Trouble differentiating between important and unimportant details
0 Deficient  Insufficient knowledge or skill
 Inappropriate and/or inflexible attitude
N/A Not Applicable:  Insufficient data; no opportunity to demonstrate; not observed
RELATIONSHIP (INTERPERSONAL)
Students will develop and maintain effective ethical and professional therapeutic relationships. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of impact of self on others. 2
Shows respect for clients. 2
Can establish an effective working alliance with clients 2
Accurately understands client communications. 2
Demonstrates appropriate professional presentation of self. 2
Effectively manages responsibilities. 2
Shows respect for colleagues from other theoretical
orientations and professional disciplines.
2
Conforms to agency expectations in scheduling, absences, 3

20. PsyD III Practicum Evaluation 2
Revised 08/06
submittal of reports, and other aspects of conducting business.
Prepares for supervision (e.g., brings relevant material for
discussion).
3
Approaches supervision in an open and collaborative manner. 2
Incorporates supervisor’s feedback into professional work. 2
Seeks out extra supervision when necessary. 2
Apply ethical principles of clinical psychology and relevant law to the practice of clinical psychology. To this end,
student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Behaves in accordance with the APA Code of Ethics and Texas
state law.
3
Shows knowledge of and ability to employ ethical standards in
professional relations.
3
Follows ethical guidelines regarding the use and dissemination
of private and confidential information.
3
Can complete a thoughtful and informed ethical decision-
making procedure.
3
Overall Proficiency Expected Demonstrated
Relationship Competency 3
Please provide specific examples of behavior that led to the above proficiency ratings.
DIVERSITY
Students will competently conceptualize and deliver diagnostic and therapeutic services by demonstrating: (a) awareness
of how own cultural background mediates interventions, (b) knowledge of multicultural concepts that are likely to affect
interventions, and (c) skills in providing effective interventions. To this end, the student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of own diversity issues and willing to self-reflect on
issues of diversity.
2
Demonstrates knowledge of diversity issues consistent with
APA guidelines on multicultural issues related to practice with
clients of diverse backgrounds
2
Can provide interventions appropriate to people of diverse
populations
2
Overall Proficiency Expected Demonstrated
Diversity Competency 2
Please provide specific examples of behavior that led to the above proficiency ratings.

21. PsyD III Practicum Evaluation 3
Revised 08/06
ASSESSMENT
Students will deliver assessment and diagnostic services in a manner consistent with professional and ethical standards
by effectively assessing and conceptualizing the strengths and problems of clients through a variety of appropriate
assessment techniques and accurately communicating findings in a professional manner. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can assess potential dangerousness of client’s behavior to self
and others.
2
Can formulate an initial treatment plan based on
diagnostic/intake interview
2
Demonstrates knowledge of psychometric principles and
limitations of assessment instruments.
2
Can select, administer, interpret, and synthesize results from
intelligence, personality and other instruments.
2
Please list tests:
Can integrate test data with clinical observations and make a
multiaxial diagnosis.
2
Can evaluate cultural and diversity influences intelligence,
personality, and other psychological measures.
2
Write clear, grammatical, well-organized, and well-reasoned professional reports and papers. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can write grammatically correct, clear, and concise reports in a
language appropriate to the report’s referral source. (e.g.,
psychologist, attorney, patient)
2
Can summarize and integrate test data (e.g., cognitive,
neuropsychological, personality) into a well-written report.
2
Can write clear concise case reports, treatment plans, and
progress notes.
2
Overall Proficiency Expected Demonstrated
Assessment Competency 2
Please provide specific examples of behavior that led to the above proficiency ratings.

22. PsyD III Practicum Evaluation 4
Revised 08/06
INTERVENTION
Students will demonstrate competent interventions consistent with current ethical, scientific, and professional standards
that are (a) delivered from a specific theoretical and methodological orientation and (b) evaluated for effectiveness. To
this end, the student:
Primary theoretical orientation practiced at practicum:
KSA Expected
Proficiency
Demonstrated
Proficiency
Understands key theoretical concepts of orientation noted
above.
2
Can apply key concepts of orientation noted above to
treatment planning with clients.
2
Can apply key concepts of orientation noted above to
conceptualizing course of psychotherapy with clients.
2
Employ psychotherapy interventions consistent with above noted orientation with clients. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Demonstrates competency in using orientation noted above: 2
Understands complexity of client problems. 2
Can assist clients in setting realistic treatment goals. 2
Can identify, carry out, and evaluate the quality and
effectiveness of therapeutic interventions.
2
Can adjust interventions according to phases and stages of
relationships and therapeutic settings.
2
Overall Proficiency Expected Demonstrated
Intervention Competency 2
Please provide specific examples of behavior that led to the above proficiency ratings.
OVERALL EVALUATION
Please describe the student’s strengths as a graduate student in clinical psychology.
Please describe aspects of the student’s work as a potential clinical psychologist that might benefit from additional supervision or
mentoring.

23. PsyD III Practicum Evaluation 5
Revised 08/06
Do any of the above areas needing additional supervision or mentoring need to be referred to the Clinical Training
Committee? (Check one:) No Yes
If Yes, please explain:
Email to AUDClinicalTraining@argosyu.edu
Supervisor’s Signature Date Student’s Signature Date
License Type: ; Number:
Received by Training Department Date

24. For use by Training Department Only
CR NC I
1 Revised 08/06
PSYD PRACTICUM EVALUATION FORM
ARGOSY UNIVERSITY/DALLAS –COLLEGE OF PSYCHOLOGY AND BEHAVIORAL SCIENCES
Student Name: Practicum Site Name:
Site Director: Site Director Email:
Primary Site Supervisor: Primary Supervisor Email:
Secondary Site Supervisor: Secondary Site Email:
Semester: Site Phone:
Dates
Evaluated
From: To: Practicum Type: PsyD IV
The doctoral program in clinical psychology at Argosy University aspires to train students within a Practitioner-Scholar Model to be proficient
in the National Council of Schools of Professional Psychology (NCSPP) competencies. The practicum placements help develop and evaluate
the student’s competency in relationships, diversity, assessment, and intervention. The primary practicum supervisor completes this form at the
end of each semester of the practicum (e.g., December, May, August). This form documents the students progress toward expected levels of
proficiency The primary supervisor is encouraged to email (AUDClinicalTraining@argosyu.edu) this form
without a signature or may alternately fax this form with a signature to the Director of Clinical Training (214)
459-2225.
The primary supervisor should assess proficiency in the specific competency listed below based on this scale keeping
two things in mind: (a) the student’s demonstrated proficiency in the competency area and (b) the expected proficiency
noted on this rating form.
3 Proficient:  Perceives situations as wholes rather than component parts
 Learns from their practice what typical things to expect in a given situation
 Plans for the need to modify responses to changes in situations
2 Intermediate:  Brings growing knowledge base to bear on interventions
 Ability to generalize skills to new situations is still limited
 Support is needed to guide performance
1 Novice:  Limited knowledge and perception of how to intervene or assess
 Limited awareness of self
 Knowledge of general principles or specific techniques to use but limited experience
restricts the flexibility of using these skills
 Trouble differentiating between important and unimportant details
0 Deficient  Insufficient knowledge or skill
 Inappropriate and/or inflexible attitude
N/A Not Applicable:  Insufficient data; no opportunity to demonstrate; not observed
RELATIONSHIP (INTERPERSONAL)
Students will develop and maintain effective ethical and professional therapeutic relationships. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of impact of self on others. 3
Shows respect for clients. 3
Can establish an effective working alliance with clients 3
Accurately understands client communications. 3
Demonstrates appropriate professional presentation of self. 3
Effectively manages responsibilities. 3
Shows respect for colleagues from other theoretical
orientations and professional disciplines.
3
Conforms to agency expectations in scheduling, absences, 3

25. PsyD IV Practicum Evaluation 2
Revised 08/06
submittal of reports, and other aspects of conducting business.
Prepares for supervision (e.g., brings relevant material for
discussion).
3
Approaches supervision in an open and collaborative manner. 3
Incorporates supervisor’s feedback into professional work. 3
Seeks out extra supervision when necessary. 3
Apply ethical principles of clinical psychology and relevant law to the practice of clinical psychology. To this end,
student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Behaves in accordance with the APA Code of Ethics and Texas
state law.
3
Shows knowledge of and ability to employ ethical standards in
professional relations.
3
Follows ethical guidelines regarding the use and dissemination
of private and confidential information.
3
Can complete a thoughtful and informed ethical decision-
making procedure.
3
Overall Proficiency Expected Demonstrated
Relationship Competency 3
Please provide specific examples of behavior that led to the above proficiency ratings.
DIVERSITY
Students will competently conceptualize and deliver diagnostic and therapeutic services by demonstrating: (a) awareness
of how own cultural background mediates interventions, (b) knowledge of multicultural concepts that are likely to affect
interventions, and (c) skills in providing effective interventions. To this end, the student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Is aware of own diversity issues and willing to self-reflect on
issues of diversity.
3
Demonstrates knowledge of diversity issues consistent with
APA guidelines on multicultural issues related to practice with
clients of diverse backgrounds
3
Can provide interventions appropriate to people of diverse
populations
3
Overall Proficiency Expected Demonstrated
Diversity Competency 3
Please provide specific examples of behavior that led to the above proficiency ratings.

26. PsyD IV Practicum Evaluation 3
Revised 08/06
ASSESSMENT
Students will deliver assessment and diagnostic services in a manner consistent with professional and ethical standards
by effectively assessing and conceptualizing the strengths and problems of clients through a variety of appropriate
assessment techniques and accurately communicating findings in a professional manner. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can assess potential dangerousness of client’s behavior to self
and others.
3
Can formulate an initial treatment plan based on
diagnostic/intake interview
3
Demonstrates knowledge of psychometric principles and
limitations of assessment instruments.
3
Can select, administer, interpret, and synthesize results from
intelligence, personality and other instruments.
3
Please list tests:
Can integrate test data with clinical observations and make a
multiaxial diagnosis.
3
Can evaluate cultural and diversity influences intelligence,
personality, and other psychological measures.
3
Write clear, grammatical, well-organized, and well-reasoned professional reports and papers. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Can write grammatically correct, clear, and concise reports in a
language appropriate to the report’s referral source. (e.g.,
psychologist, attorney, patient)
3
Can summarize and integrate test data (e.g., cognitive,
neuropsychological, personality) into a well-written report.
3
Can write clear concise case reports, treatment plans, and
progress notes.
3
Overall Proficiency Expected Demonstrated
Assessment Competency 3
Please provide specific examples of behavior that led to the above proficiency ratings.
INTERVENTION
Students will demonstrate competent interventions consistent with current ethical, scientific, and professional standards
that are (a) delivered from a specific theoretical and methodological orientation and (b) evaluated for effectiveness. To
this end, the student:
Primary theoretical orientation practiced at practicum:
KSA Expected
Proficiency
Demonstrated
Proficiency
Understands key theoretical concepts of orientation noted
above.
3

27. PsyD IV Practicum Evaluation 4
Revised 08/06
Can apply key concepts of orientation noted above to
treatment planning with clients.
3
Can apply key concepts of orientation noted above to
conceptualizing course of psychotherapy with clients.
3
Employ psychotherapy interventions consistent with above noted orientation with clients. To this end, student:
KSA Expected
Proficiency
Demonstrated
Proficiency
Demonstrates competency in using orientation noted above: 3
Understands complexity of client problems. 3
Can assist clients in setting realistic treatment goals. 3
Can identify, carry out, and evaluate the quality and
effectiveness of therapeutic interventions.
3
Can adjust interventions according to phases and stages of
relationships and therapeutic settings.
3
Overall Proficiency Expected Demonstrated
Intervention Competency 3
Please provide specific examples of behavior that led to the above proficiency ratings.
OVERALL EVALUATION
Please describe the student’s strengths as a graduate student in clinical psychology.
Please describe aspects of the student’s work as a potential clinical psychologist that might benefit from additional supervision or
mentoring.
Do any of the above areas needing additional supervision or mentoring need to be referred to the Clinical Training
Committee? (Check one:) No Yes
If Yes, please explain:
Email to AUDClinicalTraining@argosyu.edu
Supervisor’s Signature Date Student’s Signature Date
License Type: ; Number:
Received by Training Department Date

28. PsyD IV Practicum Evaluation 5
Revised 08/06