Supervisee Name____________________________________


Supervision Period_____________________to____________________


Supervisor Name_____________________________ Date of Evaluation___________


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 supervisorí»s competence as a supervisor.


Performance Level Rating Scale:           Based on current assessment and progress of supervision and expectations of supervisee:


                        3 ĘC much more of this is needed

                        2 ĘC it would be desirable to have somewhat more

                        1 ĘC it would be desirable to have a little more

                        0 ĘC this area is satisfactory


Directions:        Utilizing the Rating Scale above, place the appropriate number on the line provided at the end of each item.


Evaluation Items


Supervisor is able to:


1.  Be flexible and responsive to your changing needs                                        _______

2.  Establish an atmosphere of acceptance and psychological safety                               _______         

3.  Call attention to errors in a tactful manner                   &nbs;  _______

4.  Recognize and accommodate to your level of experience and style

     of learning                                                                                                                _______

5.  Refrain from indiscriminate use of praise                                                                   _______

6.  Provide opportunities for you to question, challenge or doubt                                    _______

7.  Encourage you to explore the implications of your interventions                                 _______

8.  Encourage you to formulate your understanding of the case material              _______

9.  Make specific suggestions when you need them                                                        _______

10. Not foster undue dependence on your part                                                  _______

11. When asked, present a clear, theoretical rationale for suggestions                 _______

12. Clearly inform you of legal issues                                                                 _______

13. Clearly inform you of ethical issues                                                              _______

14. Be sensitive to the requirements placed on you by your agency                                _______

15. Admit errors and/or limitations without undue defensiveness                         _______

16. Be concrete and specific in comments                                                                     _______

17.    Facilitate your understanding of countertransference reactions

to your clients                                                                                                  _______

      18.  Seek consultation when it is needed                                                                  _______

      19.  Summarize and/or highlight major points of supervisory session             _______

      20. Be reached in case of emergencies                                                                   _______

      21. Help you formulate the dynamics of the client                                        _______

      22.  Listen sensitively to you                                                                                    _______

23.    Help clarify and define the nature of problem(s) you are

having in your work                                                                                         _______

      24.  Be clear about the limits of the supervisory relationship                         _______

      25.  Deal explicitly with the formal evaluation process                                              _______

26.    Through role-playing or other suitable techniques, to help you

more effectively intervene with your client                                                         _______

27.    Be straightforward with you regarding areas in which you need

improvement                                                                                                    _______

28.    Be clear with you about the differences between supervision

and psychotherapy                                                                                           _______

      29.  Maintain an appropriate focus in your sessions                                      _______

30.  í░Be thereí▒ to meet your needs and not impose his/her issues on you      _______

31.  Be open to discussing any difficulties between the two of you

which are hindering your learning                                                                      _______

32.    Clearly define the nature, structure, expectations, and limitations

of the supervisory relationship                                                              _______

      33. Make decisions and take responsibility when appropriate                                 _______

      34.  Make you feel s/he genuinely want to help you learn                             _______

      35.  Be a good role model for you                                                               _______

      36.  Provide you with general knowledge about professional psychology      _______

37.    Be sensitive and adaptive to the stresses you are experiencing

 as a student                                                                                                     _______


Summarize the supervisorí»s strengths and weaknesses as you currently view them and make suggestions for ways in which your supervisor could further facilitate your learning.














Hall-Marley (2001) developed this Supervisor Feedback form as an instrument to provide feedback to supervisors on the traineeí»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.

© Susan Hall-Marley, 2001

(Also included in Appendices of Falender, C.A., & Shafranske, E.P. (2004).  Clinical

Supervision:  A Competency-based Approach.  Washington, D.C.:  APA.