Get Iowa Chemical Dependency Evaluation

Texas Department of State Health Services Professional Licensing and Certification Unit Licensed Chemical Dependency Counselor Intern Clinical Training Institution CTI Assessment Form In order to ensure that you are receiving appropriate training DSHS requires that each training site give this evaluation form to their interns to submit to DSHS. DSHS will use this evaluation to determine which Clinical Training Institutions are in need of assistance and/or training. Name of CTI site CTI Registration Address What type of supervision did you receive How often did you receive supervision Supervisor s evaluation a* Group Individual Did you achieve your supervision objectives Yes Both No b. Rate your supervisor s knowledge Excellent Good Average Poor c* Availability of training materials d. Supervisor s availability In your opinion did you receive quality training from this site Give examples Would you recommend this training site to others If no why Intern s name Date PRIVACY NOTIFICATION With few exceptions you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http //www. dshs. state. tx. us for more information on Privacy Notification* Reference Government Code Section 552. Name of CTI site CTI Registration Address What type of supervision did you receive How often did you receive supervision Supervisor s evaluation a* Group Individual Did you achieve your supervision objectives Yes Both No b. Rate your supervisor s knowledge Excellent Good Average Poor c* Availability of training materials d. Rate your supervisor s knowledge Excellent Good Average Poor c* Availability of training materials d. Supervisor s availability In your opinion did you receive quality training from this site Give examples Would you recommend this training site to others If no why Intern s name Date PRIVACY NOTIFICATION With few exceptions you have the right to request and be informed about information that the State of Texas collects about you. Supervisor s availability In your opinion did you receive quality training from this site Give examples Would you recommend this training site to others If no why Intern s name Date PRIVACY NOTIFICATION With few exceptions you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http //www. dshs. state. tx. us for more information on Privacy Notification* Reference Government Code Section 552. Name of CTI site CTI Registration Address What type of supervision did you receive How often did you receive supervision Supervisor s evaluation a* Group Individual Did you achieve your supervision objectives Yes Both No b. Rate your supervisor s knowledge Excellent Good Average Poor c* Availability of training materials d. Supervisor s availability In your opinion did you receive quality training from this site Give examples Would you recommend this training site to others If no why Intern s name Date PRIVACY NOTIFICATION With few exceptions you have the right to request and be informed about information that the State of Texas collects about you.