Supervision and Evaluation Form (Each Session)
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AGENCY NAME
Supervisor Name
CREDENTIALS
Model of Supervision Used
Reflective, Developmental, Competency-based, etc.
Method of Supervision most frequently used
Live, Audio/video tapes, Role play, Documentation review, Process recordings, etc.
Supervisee Name
Supervisee’s Credentials/Role
i.e. MFTI, LMFT, PSW, LCSW, HV, Reh. Counselor, etc.
DATES
1 hr Individual Supervision
2 hrs Group Supervision
Supervision Period
From
To
Date of Evaluation
MM
/
DD
/
YYYY
Purpose
To provide the supervisor with an understanding of his/her job performance in relation to the supervisee, to suggest areas for improvement, to permit the student to offer feedback to the supervisor in a written form that is based on a set of clearly and previously-established criteria, and to increase the supervisor’s competence as a supervisor.
Performance Level Rating Scale
Based on current assessment and progress of supervision and expectations of supervisee:

3 – much more of this is needed
2 – it would be desirable to have somewhat more
1 – it would be desirable to have a little more
0 – this area is satisfactory
Directions
Utilizing the Rating Scale above, place the appropriate number on the line provided at the end of each item
Supervisor is able to
0
1
2
3
Be flexible and responsive to your changing needs
Establish an atmosphere of acceptance and psychological safety
Call attention to errors in a tactful manner & nbs;
Recognize and accommodate to your level of experience and style of learning
Refrain from indiscriminate use of praise
Provide opportunities for you to question, challenge or doubt
Encourage you to explore the implications of your interventions
Encourage you to formulate your understanding of the case material
Make specific suggestions when you need them
Not foster undue dependence on your part
When asked, present a clear, theoretical rationale for suggestions
Clearly inform you of legal issues
Clearly inform you of ethical issues
Be sensitive to the requirements placed on you by your agency
Admit errors and/or limitations without undue defensiveness
Be concrete and specific in comments
Facilitate your understanding of counter transference reactions to your clients
Seek consultation when it is needed
Summarize and/or highlight major points of supervisory session
Be reached in case of emergencies
Help you formulate the dynamics of the client
Listen sensitively to you
Help clarify and define the nature of problem(s) you are having in your work
Be clear about the limits of the supervisory relationship
Deal explicitly with the formal evaluation process
Through role-playing or other suitable techniques, to help you more effectively intervene with your client
Be straightforward with you regarding areas in which you need improvement
Be clear with you about the differences between supervision and psychotherapy
Maintain an appropriate focus in your sessions
“Be there” to meet your needs and not impose his/her issues on you
Be open to discussing any difficulties between the two of you which are hindering your learning
Clearly define the nature, structure, expectations, and limitations of the supervisory relationship
Make decisions and take responsibility when appropriate
Make you feel s/he genuinely want to help you learn
Be a good role model for you
Provide you with general knowledge about professional psychology
Be sensitive and adaptive to the stresses you are experiencing as a student
Clear selection
Summarize the supervisor’s strengths and weaknesses as you currently view them and make suggestions for ways in which your supervisor could further facilitate your learning.
© Susan Hall-Marley, 2001
Hall-Marley (2001) developed this Supervisor Feedback form as an instrument to provide feedback to supervisors on the trainee’s experience of supervision. The form consists of sections including atmosphere for learning, supervision style, supervision conduct, and supervision impact. It is recommended a supervisor feedback form be used a minimum of four times during the training year and ideally, more frequently. It is a tool in establishing a dialogue and a feedback loop which should enhance the supervisory alliance.

Also included in Appendices of Falender, C.A., & Shafranske, E.P. (2004). Clinical Supervision: A Competency-based Approach. Washington, D.C.: APA.
For more information,
OOH Training Department : 443.805.8927  
OOH Main Office 1.855.9. OOHHOPE (1.855.966.4467)
PW@OrganiationOfHope.org
A copy of your responses will be emailed to the address you provided.
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