TEXAS HEALTH & HUMAN SERVICES 2017-2026

TEXAS DEPARTMENT OF STATE HEALTH SERVICES PROFESSIONAL LICENSING CERTIFICATION UNIT LICENSED CHEMICAL DEPENDENCY COUNSELOR PROGRAM COUNSELOR INTERN EVALUATION PACKET Instruction Sheet This document will cover a period of one twelve week quarter. Keep and use the same document over the three month period. Fill out one section per week. Total up the score for that week. The scored sections can be filled out in any order. Section 13 is a non-scored subjective section provided for flexibility covering sick time holiday time a summing up at the last week of a quarter the setting of goals at the beginning of a quarter or however the supervisor and intern choose to use this section for that quarter. Have the supervisor initial the intern initial and enter the hours accrued as shown on the intern time sheet. At the end of the quarter add up all the scores and you will have a total out of a possible five hundred possible total points. Double this score to see the percentage for example if an intern accrues a total score of 435 this doubled is 8700 or a score of 87. Begin a new blank document for each quarter. DO NOT send this packet into DSHS* This packet is to be placed in the intern s employee file and available for review at time of audit from DSHS* For more information refer to the LCDC program rules at 25 Texas Administrative Code TAC Chapter 140 Subchapter I. You may also refer to Technical Assistance Publication TAP 21 published by the Substance Abuse and Mental Health Services Administration SAMHSA Center for Substance Abuse Treatment. Date this quarterly form started Intern Name What supervision level does this intern receive 1 Unsatisfactory 4 Exceeds Expectations I II 2 Needs Improvement 5 Clearly Outstanding III Graduate 3 Meets Expectations Complete 1 section weekly during supervision* Use the TAP 21 KSA s as a tool for scoring along with Supervisor/Intern evaluations and direct observation data* 25 TAC 140. 421 f 3 Section 1 The Intern demonstrates an ability to form effective relationships with Clients Supervisor Professional peers Other supervisory staff Other counselor interns or students Community liaisons Administrative staff Contract services Client support systems Areas for Intern to improve in this section weekly objectives in the KSA s to include reading and writing assignments QCC Initial Intern initial Date Intern Hours Accrued Total Begins counseling sessions on time Can explain counseling processes and objectives Aligns sessions to treatment plan objectives Is confident during the counseling session Expresses interest and acceptance of the client Facilitates expressions of concerns and feelings Exploration of client concerns Incorporates client concerns into session Rapport Eye Contact Encourager s Empathy Confrontation Challenging Silence Identification of goals Summarizing Total Mechanistic Inaccurate reflections/interpretations Pat answers Advice-giving Missing non-verbal cues from clients Inappropriate counselor self-disclosure Confidentiality breaches regarding peers Overly directive Terminates the counseling session smoothly Is able to make appropriate referrals Knows community resources Is able to create a behavioral client involved treatment plan Recognizes the importance of family/community systems as they apply to services/levels of care Can explain administer and interpret appropriate instruments correctly Operates from a sound rational theoretical base Demonstrates ethical behavior Committed to developing professional competencies Knowledge of agency policies procedures and regulations Knowledge of job specific functions Makes decisions based on factual data and prior experiences Provides leadership and direction within areas of responsibility Continually self evaluates and analyzes outcomes Continually strives to improve job performance Adjusts performance upon receiving feedback Locates/attempts professional growth activities in areas of need Pharmacology Cultural awareness standards Knowledge and protocols of HIV/HEP C and communicable diseases Relapse prevention and continuity of care needs Co-occurring disorders knowledge and scope of practice expectations Knowledge of client s stage of readiness/change Requirements of agency and state regulations for admission Client Rights and Client Grievance Procedures Agency and State orientation requirements Service coordination responsibilities and resources Modalities of care appropriate to client need 12-Step Programs/recovery resources and referral information Section 9 Supervisory Working alliance The intern works with me on specific goals in the supervisory session In supervision the intern demonstrates reflections on comments to him or her the client s perspective The intern demonstrates taking time to understand what the client is saying or doing When correcting my supervisee s errors with a client the intern accepts and contributes alternative ways of intervening his or her difficulties with a client situation The intern stays on track during our supervisory sessions The intern synthesizes information and develops modified treatment plan goals and objectives The intern solicits and integrates feedback related to the treatment plan The intern observes and identifies problems that might impede client progress The intern participates in interdisciplinary collaboration The intern coordinates client care within multiple disciplines and external systems The intern is proficient in acquiring and prioritizing relevant treatment information The intern maintains contact with the client referral sources and significant others The intern communicates effectively with diverse populations to substance use disorders to seek out resources and services resources for training Supervisor s Signature Signature Date After the student has seen the evaluation and has signed this report please make two copies of the report one for the student and one for the site supervisor Intern Signature My signature indicates that I have read the above report and I have discussed its content with my site supervisor.