POST-INTERNSHIP/PRACTICUM EVALUATION
Department of Psychology
University of ColoradoDenver
Clinical Psychology MA Program
Date form completed:
Name of site:
Address:
Website (if applicable):
Clinical Director/Internship Coordinator:
Phone: Email: Fax:
Regular days/hours of operation: / to
Dates of internship/practicum: Start: Finish:
Hours per week: Total hours: Salary (if any):
Supervisor(s) & titles(s):
Phone: Email:
Clinic type (check one or more):
Mental Health Center School (level: ) Emergency Shelter
Hospital College/University Prison/Correctional
Residential Treatment DetoxCenter Religious:
Other:
Clinical populations (check all that apply to your experience):
Child Outpatient Court-Ordered
Adolescent Inpatient, short-term Women & Children
Adult Inpatient, long-term Military/Veterans
Geriatrics Low-Income/Homeless Physically Disabled:
FamilyUnderserved: Other:
Primary problems (check all that apply to your experience):
Substance Abuse: Teen Pregnancy/Abortion/Adoption
Psychosis Sexual Offenders
Mood Disorders Sexual Abuse Victims
Personality Disorders Anger Management
Eating Disorders Domestic Violence
Chronic Mental Illness HIV/AIDS
Family/Relationship Problems Other Physical Illnesses:
Mental Retardation/Developmental Disabilities
Other:
Therapy type (check all that apply to your experience):
Short-Term In-Home Assessment/Evaluation
Long-Term Behavior Modification Life Skills Training
Crisis Play Therapy Parenting Skills
Individual Detoxification Job Training/Placement
Family Pharmaceutical Services Community Help and Prevention
Group Psychoeducational Other:
Other training opportunities (check all that apply to your experience):
Orientation Classes
Workshops Treatment planning
In-services Case conferences
Research Other:
Theoretical orientation(s) of your supervisor(s):
Cognitive Humanistic Family systems
Behavioral Existential Object relations
Psychodynamic Feminist Integrative
Brief/Solution-Focused Biopsychosocial Other:
Hours per week of individual supervision: group supervision:
How often did you meet with your supervisor(s)?
Duties and skills acquired:
How many other students are there? How many staff members total?
Major advantages of internship/practicum:
Major disadvantages of internship/practicum:
Other comments for prospective interns/practicum students:
Your name:
If you would be willing to discuss this site with a prospective applicant, please provide the following:
Phone number: Email:
Note to person completing form: Please save completed form as “PIPE-Site Name Here” and email directly to Allison Bashe, Ph.D., Program Director: Thank you!