Teacher:	School:

Grade Level/Subject:	Date:

U=Unsatisfactory	NI=Needs Improvement	P=Proficient	E=Excellent

Domain 1 – Planning and Preparation (circle domain rating)	U	NI	P	E
1a. Knowledge of District/School Programming & Counseling Techniques
1b. Knowledge of Students, Including Child and Adolescent Development
1c. Establishing a Counseling Plan with Goals Appropriate to the Setting and the Students Served
1d. Demonstrating Knowledge of and Access to Resources
1e. Developing a Plan to Evaluate Counseling Services
Domain 2- The Environment (circle domain rating)	U	NI	P	E
2a. Creating an Environment of Safety, Respect and Rapport
2b. Establishing a Culture For Productive Communication in the School Community
2c. Managing Routines, Procedures and Physical Space
2d. Establishing Standards of Conduct and Contributing to the Culture for Student Behavior Throughout the School
Domain 3 – Delivery of Services (circle domain rating)	U	NI	P	E
3a. Communicating Clearly and Accurately with Stakeholders
3b. Implementing Individual and Group Counseling Techniques and Activities
3c. Leveraging School, Staff, and Community Resources to Advocate for and Meet Student Needs
3d. Assessing Student Needs to Provide Program Services
3e. Demonstrates Flexibility and Responsiveness
Domain 4 – Professional Responsibility: (circle domain rating)	U	NI	P	E
4a. Reflecting on Practice
4b. Maintaining Accurate Records and Using Appropriate Data to Guide Practice
4c. Communicating With Families, Staff and Community
4d. Growing Individually and Collectively as a Professional
4e. Showing Professionalism