Evaluation Period:* A. Evaluate psychological, social, and physiological signs and symptoms of alcohol and other drug use and abuse.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Screening - The process by which the client is determined appropriate and eligible for admission to a particular program.
B. Determine the client's appropriateness for admission or referral.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Screening - The process by which the client is determined appropriate and eligible for admission to a particular program.
C. Determine the client's eligibility for admission or referral.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Screening - The process by which the client is determined appropriate and eligible for admission to a particular program.
D. Identify any coexisting conditions (medical, psychiatric, physical, etc.) that indicate need for additional professional assessment and/or services.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Screening - The process by which the client is determined appropriate and eligible for admission to a particular program.
E. Adhere to applicable laws, regulations and agency policies governing alcohol and other drug abuse services.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Screening - The process by which the client is determined appropriate and eligible for admission to a particular program.
Comments on Student Intern's Screening Skills:*
A. Provide an overview to the client by describing program goals and objectives for client care.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Orientation - Describing to the client the following; general nature and goals of the program, rules governing client conduct and infractions that can lead to a disciplinary action or discharge from the program; in a non-residential program, the hours during which services are available; treatment costs to be borne by the client, if any; and client rights.
B. Provide an overview to the client by describing program rules, and client obligations and rights.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Orientation - Describing to the client the following; general nature and goals of the program, rules governing client conduct and infractions that can lead to a disciplinary action or discharge from the program; in a non-residential program, the hours during which services are available; treatment costs to be borne by the client, if any; and client rights.
C. Provide an overview to the client program operations.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Orientation - Describing to the client the following; general nature and goals of the program, rules governing client conduct and infractions that can lead to a disciplinary action or discharge from the program; in a non-residential program, the hours during which services are available; treatment costs to be borne by the client, if any; and client rights.
Comments on Student Intern's Orientation Skills:*
A. Gather relevant history from client including but not limited to alcohol and other drug abuse using appropriate interview techniques.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Assessment – Those procedures by which a counselor/program identifies and evaluates an individual’s strengths, weaknesses, problems, and needs for the development of the treatment plan. (Minnesota Rule 31 Dimensions: Acute intoxication and withdrawal potential; Biomedical conditions and complications; Emotional and behavioral conditions and complications; Treatment acceptance, resistance; Relapse and continued use potential; and Recovery environment)
B. Identify methods and procedures for obtaining corroborative information from significant secondary source regarding client’s alcohol and other drug abuse and psycho-social history.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Assessment – Those procedures by which a counselor/program identifies and evaluates an individual’s strengths, weaknesses, problems, and needs for the development of the treatment plan. (Minnesota Rule 31 Dimensions: Acute intoxication and withdrawal potential; Biomedical conditions and complications; Emotional and behavioral conditions and complications; Treatment acceptance, resistance; Relapse and continued use potential; and Recovery environment)
C. Identify appropriate assessment tools.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Assessment – Those procedures by which a counselor/program identifies and evaluates an individual’s strengths, weaknesses, problems, and needs for the development of the treatment plan. (Minnesota Rule 31 Dimensions: Acute intoxication and withdrawal potential; Biomedical conditions and complications; Emotional and behavioral conditions and complications; Treatment acceptance, resistance; Relapse and continued use potential; and Recovery environment)
D. Explain to the client the rationale for the use of assessment techniques in order to facilitate understanding.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Assessment – Those procedures by which a counselor/program identifies and evaluates an individual’s strengths, weaknesses, problems, and needs for the development of the treatment plan. (Minnesota Rule 31 Dimensions: Acute intoxication and withdrawal potential; Biomedical conditions and complications; Emotional and behavioral conditions and complications; Treatment acceptance, resistance; Relapse and continued use potential; and Recovery environment)
E. Develop a diagnostic evaluation of the client’s substance abuse and any coexisting conditions based on the results of all assessments in order to provide an integrated approach to treatment planning based on the client’s strengths, weaknesses, and identified problems and needs.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Assessment – Those procedures by which a counselor/program identifies and evaluates an individual’s strengths, weaknesses, problems, and needs for the development of the treatment plan. (Minnesota Rule 31 Dimensions: Acute intoxication and withdrawal potential; Biomedical conditions and complications; Emotional and behavioral conditions and complications; Treatment acceptance, resistance; Relapse and continued use potential; and Recovery environment)
Comments on Student Intern's Assessment Skills:*
A. Explain assessment results to client in an understandable manner.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Treatment Planning – Process by which one counselor and the client identify and rank problems needing resolution; establish agreed upon immediate and long term goals; and decide on a treatment process and the resources to be utilized.
B. Identify and rank problems based on individual client needs in the written treatment plan.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Treatment Planning – Process by which one counselor and the client identify and rank problems needing resolution; establish agreed upon immediate and long term goals; and decide on a treatment process and the resources to be utilized.
C. Formulate agreed upon immediate and long term goals using behavioral terms in the written treatment plan.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Treatment Planning – Process by which one counselor and the client identify and rank problems needing resolution; establish agreed upon immediate and long term goals; and decide on a treatment process and the resources to be utilized.
D. Identify the treatment methods and resources to be utilized as appropriate for the individual client.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Treatment Planning – Process by which one counselor and the client identify and rank problems needing resolution; establish agreed upon immediate and long term goals; and decide on a treatment process and the resources to be utilized.
Comments on Student Intern's Assessment Skills:*
A. Select the counseling theory(ies) that apply(ies).* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Counseling – (Individual, Group, and Significant Others) The utilization of special skills to assist individuals, families, or groups in achieving objectives through exploration of a problem and its ramifications; examination of attitudes and feelings; consideration of alternative solutions; and decision making.
B. Apply technique(s) to assist the client, group, and/or family in exploring problems and ramifications.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Counseling – (Individual, Group, and Significant Others) The utilization of special skills to assist individuals, families, or groups in achieving objectives through exploration of a problem and its ramifications; examination of attitudes and feelings; consideration of alternative solutions; and decision making.
C. Apply technique(s) to assist the client, group and/or family in examining the client’s behavior, attitudes, and/or feelings if appropriate in the treatment setting.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Counseling – (Individual, Group, and Significant Others) The utilization of special skills to assist individuals, families, or groups in achieving objectives through exploration of a problem and its ramifications; examination of attitudes and feelings; consideration of alternative solutions; and decision making.
D. Individualize counseling in accordance with cultural, gender, and lifestyle differences.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Counseling – (Individual, Group, and Significant Others) The utilization of special skills to assist individuals, families, or groups in achieving objectives through exploration of a problem and its ramifications; examination of attitudes and feelings; consideration of alternative solutions; and decision making.
E. Interact with the client in an appropriate therapeutic manner.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Counseling – (Individual, Group, and Significant Others) The utilization of special skills to assist individuals, families, or groups in achieving objectives through exploration of a problem and its ramifications; examination of attitudes and feelings; consideration of alternative solutions; and decision making.
F. Elicit solutions and decisions from the client.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Counseling – (Individual, Group, and Significant Others) The utilization of special skills to assist individuals, families, or groups in achieving objectives through exploration of a problem and its ramifications; examination of attitudes and feelings; consideration of alternative solutions; and decision making.
G. Implement the treatment plan.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Counseling – (Individual, Group, and Significant Others) The utilization of special skills to assist individuals, families, or groups in achieving objectives through exploration of a problem and its ramifications; examination of attitudes and feelings; consideration of alternative solutions; and decision making.
Comments on Student Intern's Counseling Skills:*
A. Coordinate services for client care.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Case Management – Activities which bring services, agencies, resources, or people together within a planned framework of action towards the achievement of established goals. It may involve liaison activities and collateral contacts.
B. Explain the rationale of case management activities to the client.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Case Management – Activities which bring services, agencies, resources, or people together within a planned framework of action towards the achievement of established goals. It may involve liaison activities and collateral contacts.
Comments on Student Intern's Case Management Skills:*
A. Recognize the elements of the client crisis.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Crisis Intervention - Those services which correspond to an alcohol and/or other drug abuser’s needs during acute emotional and/or physical distress.
B. Implement an immediate course of action appropriate to the crisis.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Crisis Intervention - Those services which correspond to an alcohol and/or other drug abuser’s needs during acute emotional and/or physical distress.
C. Enhance overall treatment by utilizing crisis events.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Crisis Intervention - Those services which correspond to an alcohol and/or other drug abuser’s needs during acute emotional and/or physical distress.
Comments on Student Intern's Crisis Intervention Skills:*
A. Present relevant alcohol and other drug use/abuse information to the client through formal and/or informal processes.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Client Education - Provision of information to individuals and groups concerning alcohol and other drug abuse and the available services and resources.
B. Present information about available alcohol and other drug services and resources.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Client Education - Provision of information to individuals and groups concerning alcohol and other drug abuse and the available services and resources.
Comments on Student Intern's Client Education Skills:*
A. Identify need(s) and/or problems(s) that the agency and/or counselor cannot meet.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Referral - Identifying the needs of the client that cannot be met by the counselor or agency and assisting the client to utilize the support systems and community resources available.
B. Explain the rationale for the referral to the client.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Referral - Identifying the needs of the client that cannot be met by the counselor or agency and assisting the client to utilize the support systems and community resources available.
C. Attach clients' needs and/or problems to appropriate resources.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Referral - Identifying the needs of the client that cannot be met by the counselor or agency and assisting the client to utilize the support systems and community resources available.
D. Adhere to applicable laws, regulations, and agency policies governing procedures related to the protection of the client's confidentiality.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Referral - Identifying the needs of the client that cannot be met by the counselor or agency and assisting the client to utilize the support systems and community resources available.
E. Assist the client in utilizing the support systems and community resources available.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Referral - Identifying the needs of the client that cannot be met by the counselor or agency and assisting the client to utilize the support systems and community resources available.
Comments on Student Intern's Referral Skills:*
A. Prepare reports and relevant records integrating available information to facilitate the continuum of care.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Reports and record keeping - Charting the results of the assessment and treatment plan, writing reports, progress notes, discharge summaries, and other client-related data.
B. Chart pertinent on-going information pertaining to the client.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Reports and record keeping - Charting the results of the assessment and treatment plan, writing reports, progress notes, discharge summaries, and other client-related data.
C. Utilize relevant information from written documents for client care.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Reports and record keeping - Charting the results of the assessment and treatment plan, writing reports, progress notes, discharge summaries, and other client-related data.
Comments on Student Intern's Reports and Record Keeping Skills:*
A. Recognize issues that are beyond the counselor's base of knowledge and/or skill.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Consultation with other professionals in regard to client treatment/services - Relating with our own and other professionals to assure comprehensive, quality care for the client.
B. Consult with appropriate resources to ensure the provision of effective treatment services.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Consultation with other professionals in regard to client treatment/services - Relating with our own and other professionals to assure comprehensive, quality care for the client.
C. Adhere to applicable laws, regulations, and agency policies governing the disclosure of client-identifying data.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Consultation with other professionals in regard to client treatment/services - Relating with our own and other professionals to assure comprehensive, quality care for the client.
D. Explain the rationale for the consultation to the client, if appropriate.* 4 - Performs consistently in an excellent manner 3 - Usually performs in a superior manner 2 - Usually performs in an adequate manner but still needs some work 1 - Performs consistently in an inferior manner, needs extensive work N/A - Data not available to evaluate
Consultation with other professionals in regard to client treatment/services - Relating with our own and other professionals to assure comprehensive, quality care for the client.
Comments on Student Intern's Consultation Skills:*
By checking this box I verify that the required hours for the internship have been completed as indicated above. 1. Shows a positive self-concept.* Please rate the student's professionalism as a beginning LADC practitioner.
2. Is aware of personal biases.* Please rate the student's professionalism as a beginning LADC practitioner.
3. Recognizes limitations/areas of weaknesses.* Please rate the student's professionalism as a beginning LADC practitioner.
4. Accepts constructive criticism non-defensively.* Please rate the student's professionalism as a beginning LADC practitioner.
5. Is willing to try new strategies.* Please rate the student's professionalism as a beginning LADC practitioner.
6. Is open to other points of view.* Please rate the student's professionalism as a beginning LADC practitioner.
7. Shows genuine concern for others.* Please rate the student's professionalism as a beginning LADC practitioner.
8. Exhibits good work habits (attendance, completion of tasks, etc.).* Please rate the student's professionalism as a beginning LADC practitioner.
9. Abides by confidentiality and agency policies & procedures.* Please rate the student's professionalism as a beginning LADC practitioner.
10. Contributes thoughtfully to team discussions and decision-making, communicates concerns and issues appropriately.* Please rate the student's professionalism as a beginning LADC practitioner.
1. Is relaxed in the counseling session.* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
2. Establishes rapport; builds an atmosphere of acceptance.* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
3. Is aware of non-verbal as well as verbal behaviors.* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
3. Is aware of non-verbal as well as verbal behaviors.* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
4. Is able to address main issues.* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
5. Can conceptualize a case accurately.* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
6. Helps client to set appropriate goals.* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
7. Can plan and carry out appropriate strategies.* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
8. Begins and ends sessions smoothly.* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
9. Demonstrates awareness and sensitivity to multicultural issues.* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
10. Uses a variety of counseling responses (reflection, summary, confrontation, questioning, etc.).* Please rate the student's performance in the counseling relationship as a beginning LADC practitioner.
Student's Strengths in Chemical Dependency Practice To Date:*
Student's Areas for Development in Chemical Dependency Practice To Date:*
Plans for the Second Half of the Internship (Midterm Only)
By checking this box I verify that I will review this evlaution with my student intern prior to meeting with the BSU Field Director. By checking this box I verify that this evlaution has been completed by the person(s) indicated above to be the student intern's Field Instructor(s) and the required internship hours have been successfully completed. 
