“Positive Impact on Student Learning Assessment Form”
School Counseling Internship Requirement: the intern will also be required turn in “Positive Impact on Student Learning Assessment” for two students they counseled. A separate form is required for each counselee. No names are to be given on the form.
Student’s Age _____ Grade _______ Ethnicity _______ Sex __________
Referral was from: Student ____ Teacher _____ Parent ____ Administrator ___ Peer ___
Presenting Problem was:
1. List what specific measures of student learning were taken to prior to, or at the beginning of counseling, that are related to the presenting problem. List them below. These will also be the measures that will be evaluated AFTER the counseling intervention. Examples could be failing to turn in 80% of papers for a certain period of time, number of days absent, number of discipline referrals, grade point on assignments, number of disrespectful statements to teacher, current reading or achievement level test scores in a subject, test anxiety measures, etc.
2. List the specific counseling interventions (and the amount of time involved) you used to help the student. Examples could be:
____Counseling Contract: (If so please attach with the students name removed)
____Individual Counseling
____Group Counseling
____Consultations with Teachers, Staff, Parents, or Peers
____ Referral to others agencies or specialists
____Other (Please Specify)
____Total hours working with this student.
3. After the intervention, using the measures you used in 1 above, list the post measure scores and discuss briefly whether the counseling intervention showed a positive impact on student learning. If there was not a positive impact, why do you think the counseling intervention was not effective?
__________________ ________________ _________________
In-School Supervisor Counseling Intern Date