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EXTERN/FIELD PLACEMENT REFERENCE FORM
Loyola College Counseling Center
4501 N. Charles Street, HU 150
Baltimore, MD 21210
(410) 617-5109
(410) 617-2001 fax

Name of Applicant: _________________    Name of Reference: ________________
Academic Program:_________________     Reference’s Agency:_______________ 
Date: _____________________

Instructions for Reference
The above named graduate student has applied for an extern/field placement position at the Loyola College Counseling Center, and has listed you as a reference.  To assist us in providing well-matched training, please complete this form and return it sealed and signed in an envelope to the above named student, or send it directly to the Counseling Center at the address or fax number above (ATTN:  Coordinator of Extern Training).    Please comment on the clinical capabilities of this individual based on your supervision and use concrete examples whenever possible.  Thank you for your reflective appraisal of this student.

Dates Supervised Applicant: ______________________________

Using the rating scale below, provide a numeric rating for each dimension listed or write N/A for “not applicable.”

5 - Regularly exceeds expectations
4 - Occasionally exceeds expectations
3 - Regularly meets expectations 
2 - Occasionally falls below expectations    
1 - Regularly falls below expectations  

I. Individual Therapy Skills:
A. Facilitative Dimensions of Counseling/Therapy
____ listening skills
____ empathy
____ ability to establish a therapeutic relationship
____ ability to develop treatment goals
____ ability to terminate relationship
Comments:

B. Knowledge of Client
____ ability to elicit essential data from client
____ understanding significance of data
____ ability to assess client strengths and weaknesses
Comments:

C.  Conceptualization
____ generates hypotheses of client behavior and dynamics based on assessment
____ formulates appropriate interventions based on conceptualization
Comments:

D.  Relationship with Client
____ sensitivity to client concerns, willingness to discuss transference/counter-     
       transference issues
____ ability to understand and reflect client feelings
____ shows awareness of personal style and appropriately uses self in counseling
Comments:

II.  Awareness of and Sensitivity to Cultural Issues
A.  Awareness of Diversity
___sensitivity to client issues of diversity
___awareness of how one’s own culture effects clients
Comments:

B.  Ability to Intervene on Issues of Diversity
___ ability to work with clients from a variety of backgrounds
___ appropriately discusses relevant identity dimensions and impact on therapy
      and relationship with clients
___ raises diversity issues in supervision
Comments:

III.  Ethics and Professionalism
A.  Ethics
___ identifies ethical concerns
___ demonstrates ethical behavior
Comments:

B.  Professionalism
___ works within agency guidelines and procedures
___ demonstrates awareness of his/her impact on colleagues
___ manages personal issues so that they do not impair professional functioning
Comments:

IV.  Administration/Case Management
A.  Paperwork
___ system of up-to-date record keeping
___ keeps client materials confidential and secure
___ timely completion of termination summaries
Comments:

B.  Scheduling
____ keeps scheduled appointments
____ on time for appointments
____ makes contact quickly with clients who missed appointments
____ ends sessions on time
Comments:

V.  Supervision
____ demonstrates willingness to explore and improve on growth edges
____ accepts responsibility in supervision
____ actively solicits feedback from supervisor
____ critiques and analyzes own session tapes
____ attempts to apply insights from supervision to clinical work
____ appreciates own strengths
____ willingness to explore how own interpersonal perspectives impact counseling           
____ willingness to explore how own interpersonal perspectives impact supervision
Comments:

Based on other supervisees at this student’s level of training, please provide a summary of the applicant’s strengths and growing edges.

STRENGTHS:

GROWING EDGES:

Signature:  ______________________                    Date:______________