Clinical Supervision - 2024 Survey

The Clinical Supervision survey is a targeted assessment tool utilized by supervisors to observe and evaluate the performance of their staff members. It involves structured observations of employees' work habits, interactions, and adherence to policies and procedures. This survey provides valuable insights into individual performance, identifies strengths and areas for development, and enables supervisors to provide constructive feedback and support to enhance overall productivity and effectiveness within the team.

	Exceptional	Adequate	Needs Improvement (Comment Required)	N/A
Accuracy of assessment and referral skills.	Accuracy of assessment and referral skills. Exceptional	Accuracy of assessment and referral skills. Adequate	Accuracy of assessment and referral skills. Needs Improvement (Comment Required)	Accuracy of assessment and referral skills. N/A
Appropriateness of the treatment/service intervention selected relative to client's specific needs.	Appropriateness of the treatment/service intervention selected relative to client's specific needs. Exceptional	Appropriateness of the treatment/service intervention selected relative to client's specific needs. Adequate	Appropriateness of the treatment/service intervention selected relative to client's specific needs. Needs Improvement (Comment Required)	Appropriateness of the treatment/service intervention selected relative to client's specific needs. N/A
Treatment/service effectiveness as reflected by the client meeting their individual goals.	Treatment/service effectiveness as reflected by the client meeting their individual goals. Exceptional	Treatment/service effectiveness as reflected by the client meeting their individual goals. Adequate	Treatment/service effectiveness as reflected by the client meeting their individual goals. Needs Improvement (Comment Required)	Treatment/service effectiveness as reflected by the client meeting their individual goals. N/A
Risk factors for suicide and other dangerous behaviors.	Risk factors for suicide and other dangerous behaviors. Exceptional	Risk factors for suicide and other dangerous behaviors. Adequate	Risk factors for suicide and other dangerous behaviors. Needs Improvement (Comment Required)	Risk factors for suicide and other dangerous behaviors. N/A
Provision of feedback from Supervisee to Supervisor.	Provision of feedback from Supervisee to Supervisor. Exceptional	Provision of feedback from Supervisee to Supervisor. Adequate	Provision of feedback from Supervisee to Supervisor. Needs Improvement (Comment Required)	Provision of feedback from Supervisee to Supervisor. N/A
Issues of ethics, legal aspects of clinical practice, boundaries, and professional standards.	Issues of ethics, legal aspects of clinical practice, boundaries, and professional standards. Exceptional	Issues of ethics, legal aspects of clinical practice, boundaries, and professional standards. Adequate	Issues of ethics, legal aspects of clinical practice, boundaries, and professional standards. Needs Improvement (Comment Required)	Issues of ethics, legal aspects of clinical practice, boundaries, and professional standards. N/A
Clinical documentation issues identified through ongoing compliance review.	Clinical documentation issues identified through ongoing compliance review. Exceptional	Clinical documentation issues identified through ongoing compliance review. Adequate	Clinical documentation issues identified through ongoing compliance review. Needs Improvement (Comment Required)	Clinical documentation issues identified through ongoing compliance review. N/A
Cultural competency issues.	Cultural competency issues. Exceptional	Cultural competency issues. Adequate	Cultural competency issues. Needs Improvement (Comment Required)	Cultural competency issues. N/A
Model fidelity re:evidence-based practices.	Model fidelity re:evidence-based practices. Exceptional	Model fidelity re:evidence-based practices. Adequate	Model fidelity re:evidence-based practices. Needs Improvement (Comment Required)	Model fidelity re:evidence-based practices. N/A

Exceptional

Adequate

Needs Improvement (Comment Required)

N/A

Accuracy of assessment and referral skills.

Accuracy of assessment and referral skills. Exceptional

Accuracy of assessment and referral skills. Adequate

Accuracy of assessment and referral skills. Needs Improvement (Comment Required)

Accuracy of assessment and referral skills. N/A

Appropriateness of the treatment/service intervention selected relative to client's specific needs.

Appropriateness of the treatment/service intervention selected relative to client's specific needs. Exceptional

Appropriateness of the treatment/service intervention selected relative to client's specific needs. Adequate

Appropriateness of the treatment/service intervention selected relative to client's specific needs. Needs Improvement (Comment Required)

Appropriateness of the treatment/service intervention selected relative to client's specific needs. N/A

Treatment/service effectiveness as reflected by the client meeting their individual goals.

Treatment/service effectiveness as reflected by the client meeting their individual goals. Exceptional

Treatment/service effectiveness as reflected by the client meeting their individual goals. Adequate

Treatment/service effectiveness as reflected by the client meeting their individual goals. Needs Improvement (Comment Required)

Treatment/service effectiveness as reflected by the client meeting their individual goals. N/A

Risk factors for suicide and other dangerous behaviors.

Risk factors for suicide and other dangerous behaviors. Exceptional

Risk factors for suicide and other dangerous behaviors. Adequate

Risk factors for suicide and other dangerous behaviors. Needs Improvement (Comment Required)

Risk factors for suicide and other dangerous behaviors. N/A

Provision of feedback from Supervisee to Supervisor.

Provision of feedback from Supervisee to Supervisor. Exceptional

Provision of feedback from Supervisee to Supervisor. Adequate

Provision of feedback from Supervisee to Supervisor. Needs Improvement (Comment Required)

Provision of feedback from Supervisee to Supervisor. N/A

Issues of ethics, legal aspects of clinical practice, boundaries, and professional standards.

Issues of ethics, legal aspects of clinical practice, boundaries, and professional standards. Exceptional

Issues of ethics, legal aspects of clinical practice, boundaries, and professional standards. Adequate

Issues of ethics, legal aspects of clinical practice, boundaries, and professional standards. Needs Improvement (Comment Required)

Issues of ethics, legal aspects of clinical practice, boundaries, and professional standards. N/A

Clinical documentation issues identified through ongoing compliance review.

Clinical documentation issues identified through ongoing compliance review. Exceptional

Clinical documentation issues identified through ongoing compliance review. Adequate

Clinical documentation issues identified through ongoing compliance review. Needs Improvement (Comment Required)

Clinical documentation issues identified through ongoing compliance review. N/A

Cultural competency issues.

Cultural competency issues. Exceptional

Cultural competency issues. Adequate

Cultural competency issues. Needs Improvement (Comment Required)

Cultural competency issues. N/A

Model fidelity re:evidence-based practices.

Model fidelity re:evidence-based practices. Exceptional

Model fidelity re:evidence-based practices. Adequate

Model fidelity re:evidence-based practices. Needs Improvement (Comment Required)

Model fidelity re:evidence-based practices. N/A

	Exceptional	Adequate	Needs Improvement (Comment Required)	N/A
Emergency Response	Emergency Response Exceptional	Emergency Response Adequate	Emergency Response Needs Improvement (Comment Required)	Emergency Response N/A
Appropriate use of supervision	Appropriate use of supervision Exceptional	Appropriate use of supervision Adequate	Appropriate use of supervision Needs Improvement (Comment Required)	Appropriate use of supervision N/A
Insight into client problems	Insight into client problems Exceptional	Insight into client problems Adequate	Insight into client problems Needs Improvement (Comment Required)	Insight into client problems N/A
Concern for welfare of client	Concern for welfare of client Exceptional	Concern for welfare of client Adequate	Concern for welfare of client Needs Improvement (Comment Required)	Concern for welfare of client N/A
Attendance and punctuality	Attendance and punctuality Exceptional	Attendance and punctuality Adequate	Attendance and punctuality Needs Improvement (Comment Required)	Attendance and punctuality N/A
Objectivity	Objectivity Exceptional	Objectivity Adequate	Objectivity Needs Improvement (Comment Required)	Objectivity N/A
Boundaries	Boundaries Exceptional	Boundaries Adequate	Boundaries Needs Improvement (Comment Required)	Boundaries N/A
Personal Integrity	Personal Integrity Exceptional	Personal Integrity Adequate	Personal Integrity Needs Improvement (Comment Required)	Personal Integrity N/A
Interactions with co-workers	Interactions with co-workers Exceptional	Interactions with co-workers Adequate	Interactions with co-workers Needs Improvement (Comment Required)	Interactions with co-workers N/A
Recognition of own limits	Recognition of own limits Exceptional	Recognition of own limits Adequate	Recognition of own limits Needs Improvement (Comment Required)	Recognition of own limits N/A
Continuing education (trainings)	Continuing education (trainings) Exceptional	Continuing education (trainings) Adequate	Continuing education (trainings) Needs Improvement (Comment Required)	Continuing education (trainings) N/A

Exceptional

Adequate

Needs Improvement (Comment Required)

N/A

Emergency Response

Emergency Response Exceptional

Emergency Response Adequate

Emergency Response Needs Improvement (Comment Required)

Emergency Response N/A

Appropriate use of supervision

Appropriate use of supervision Exceptional

Appropriate use of supervision Adequate

Appropriate use of supervision Needs Improvement (Comment Required)

Appropriate use of supervision N/A

Insight into client problems

Insight into client problems Exceptional

Insight into client problems Adequate

Insight into client problems Needs Improvement (Comment Required)

Insight into client problems N/A

Concern for welfare of client

Concern for welfare of client Exceptional

Concern for welfare of client Adequate

Concern for welfare of client Needs Improvement (Comment Required)

Concern for welfare of client N/A

Attendance and punctuality

Attendance and punctuality Exceptional

Attendance and punctuality Adequate

Attendance and punctuality Needs Improvement (Comment Required)

Attendance and punctuality N/A

Objectivity

Objectivity Exceptional

Objectivity Adequate

Objectivity Needs Improvement (Comment Required)

Objectivity N/A

Boundaries

Boundaries Exceptional

Boundaries Adequate

Boundaries Needs Improvement (Comment Required)

Boundaries N/A

Personal Integrity

Personal Integrity Exceptional

Personal Integrity Adequate

Personal Integrity Needs Improvement (Comment Required)

Personal Integrity N/A

Interactions with co-workers

Interactions with co-workers Exceptional

Interactions with co-workers Adequate

Interactions with co-workers Needs Improvement (Comment Required)

Interactions with co-workers N/A

Recognition of own limits

Recognition of own limits Exceptional

Recognition of own limits Adequate

Recognition of own limits Needs Improvement (Comment Required)

Recognition of own limits N/A

Continuing education (trainings)

Continuing education (trainings) Exceptional

Continuing education (trainings) Adequate

Continuing education (trainings) Needs Improvement (Comment Required)

Continuing education (trainings) N/A

Clinical Supervision - 2024

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* 1. Employee Name

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* 2. Supervision Date

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* 3. Supervisor Name

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* 4. Supervision Type

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* 5. Ongoing Supervisory Issues: Items 1 and 2 must be addressed once every 6 months.

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* 6. Comments (spefic to "Needs Improvement" response

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* 7. Other Areas

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* 8. Comments (Specific to "Needs Improvement" response