Telehealth Consultation Feedback Form

“Competence comes when successful outcomes are produced by values-driven, purposeful behaviors.” - Aubrey C. Daniels

Consultant Name Date Observed Observing Supervisor

Click or tap to enter a date.

Consultation Coaching Model: Research indicates that parents and professionals alike define collaborative partnerships in terms of the quality of
their interpersonal relationships with each other (McWilliam, Tocci, & Harbin, 1998). Collaborative partnerships characterized by factors such as
trust, respect, communication, shared vision and cultural humility are identified as critical for effective partnerships with families (Parette,
Brotherson, & Huer, 2000).

Instructions: For each item/domain, check the rating that corresponds with the statements that best describes the consultant’s skill set. Use the
below key as a guide. If you feel that the statement does not provide an entirely complete or accurate portrayal, use the notes section to more
specifically define feedback. Assign a total for each section and add up points on the last page to determine overall score.

Performance management key:

Competent Highly Competent

Needs Improvement (0pts) Superior (3pts)
Meets Expectations (1pt) Exceeds Expectations (2pts)
 Corrective feedback (e.g.  Competent  Highly competent  Superior competency
behaviorally anchored,  Meets expectations  Exceeds expectations  Surpasses expectations
corrective feedback)  Maintains quality assurance  Driver of quality assurance  Model of quality assurance
 Performance supports (e.g.
observe consultant(s),
performance plan)
 Recommended clinical
supports (e.g. attending
CEU’s, additional clinical
resources, scope of practice)
Effective Communication, Interpersonal Skills and Cultural/Linguistic Humility: Clearly conveying and receiving information and ideas
through a skill set that engages the parent/caregiver, helps the parent/caregiver understand and retain the information, engages response and
feedback from the parent/caregiver and demonstrates cultural and linguistic humility. Searches for ways to improve the parent/caregiver
experience.
Rate performance in the following area:
Target Behavior ☐ Needs Improvement (0pts)
 Communication is
frequently one-way, fails to
process
 Communication is
unfriendly, unorganized
 Excessive use of filler
words, phrases (umm, like
I said, etc.)
 Excessive use of clinical
jargon, does not reframe
Communication language to fit parent level
of knowledge
 Communication is
generally not clear or
engaging to the parent,
uses complex wording
 Takes few steps to
improve parent/caregiver
experience
 Other:
Feedback/Notes:
_________ TOTAL POINTS
☐ Competent ☐ Highly Competent
Meets Expectations (1pt) Exceeds Expectations (2pts)
 Demonstrates  Demonstrates highly
effective and effective and professional
professional communication (e.g.
communication (e.g. friendly, polite, builds trust,
friendly, polite, builds well-organized, clear and
trust, well-organized, concise, incorporates input,
clear and concise, feedback and response of
incorporates input, parent)
feedback and  Highly effective in
response of parent) communicating information
 Communicates in a manner focused on the
information in a parent/caregiver’s
manner focused on perspective and level of
the parent/caregiver’s knowledge
perspective and level  Accurately restates the
of knowledge parent’s message in
different words and terms
while also considering
cultural and linguistic
humility
☐ Superior (3pts)
 Superior in professional
communication (e.g. friendly,
polite, builds trust, well-
organized, clear and concise,
incorporate input, feedback
and response of parent)
 Superior when communicating
information in a manner
focused on the
parent/caregiver’s perspective
and level of knowledge
 Highly effective in accurately
restating the parent’s
message in different words
and terms while also
considering cultural and
linguistic humility
 Actively seeks feedback from
parent/caregiver to identify
ways to continuously improve
experience
Rate performance in the following area:
☐ Needs Improvement
Target Behavior
(0pts)
 Demonstrates a lack of
empathy when
communicating with
parents
 Demonstrates a lack of
active listening (e.g.
reflect parent
communication, asks
appropriate questions to
clarify
information/needs)
 Demonstrates a lack of
Interpersonal ability to stop at certain
Skills points and
describe/attend to key
points being
discussed/demonstrated
 Demonstrates a lack of
good judgment about
what to say and when to
say it, lacks
effectiveness when
gathering information to
assist in clarification and
identifying needs
 Other:
Feedback/Notes:
☐ Competent ☐ Highly Competent
Meets Expectations (1pt) Exceeds Expectations (2pts)
 Demonstrates empathy  Highly effective in
when communicating demonstrating empathy
with parents when communicating with
 Actively listens (e.g. parents
reflects parent  Highly effective active
communication, asks listening (e.g. reflects
appropriate questions to parent communication, asks
clarify appropriate questions to
information/needs) clarify information/needs,
 Demonstrates the ability summarizes information)
to stop at certain points  Demonstrates highly
and describe/attend to effective ability to stop at
key points being certain points and
discussed/demonstrated describe/attend to key
 Exercises judgment points being
about what to say and discussed/demonstrated
when to say it, effective  Exercises sound judgment
when gathering about what to say and when
information to assist in to say it, highly effective
clarification and when gathering information
identifying needs to assist in clarification and
identifying needs
_________ TOTAL POINTS
☐ Superior (3pts)
 Superior in demonstrating
empathy when
communicating with parents
 Superior in active listening
(e.g. reflects parent
communication, asks
appropriate questions to
clarify information/needs,
summarizes information)
 Superior ability to stop at
certain points and
describe/attend to key
points being
discussed/demonstrated
 Exercises superior judgment
about what to say and when
to say it, highly effective
when gathering information
to assist in clarification and
identifying needs
Rate performance in the following area:
Target Behavior Needs Improvement (0pts)
 Demonstrates a lack of
cultural and linguistic
humility
 Demonstrates a lack of
ability to foster an
environment during session
where ideas and input are
readily welcomed,
encouraged and shared
 Takes few steps to improve
the parent/caregiver
experience
Cultural Humility  Takes few steps to actively
seek feedback from
parent/caregiver to identify
ways to continuously
improve experience with
cultural and linguistic
humility
 Other:
Feedback/Notes:
_________ TOTAL POINTS
Highly Competent
Competent
Exceeds Expectations Superior (3pts)
Meets Expectations (1pt)
(2pts)
 Demonstrates cultural  Highly competent in  Superior competence in
and linguistic humility, demonstrating cultural demonstrating cultural
fosters an environment and linguistic humility, and linguistic humility,
during session where fosters an environment fosters an environment
ideas and input are during session where during session where
readily welcomed, ideas and input are ideas and input are
encouraged and shared readily welcomed, readily welcomed,
 Seeks feedback from encouraged and shared encouraged and shared
parents regularly  Summarizes and  Highly effective in
reinforces summarizing and
parent/caregiver reinforcing parent
behavior(s) (e.g. behavior(s) (e.g.
strengths and family strengths and family
dynamics) dynamics, culture)
 Seeks feedback solicits, listens to and
frequently from parents acknowledges family
culture
 Actively seeks
feedback from
parent/caregiver to
identify ways to
continuously improve
experience with cultural
and linguistic humility
Professionalism, Clinical Knowledge and Coaching Model: Possessing, acquiring, and maintaining the clinical/professional expertise required
to consult effectively and to create parent/caregiver solutions and outcomes. Clinical/professional expertise is demonstrated through problem
solving, applying clinical knowledge, applying coaching knowledge and product management, demonstrates cultural and linguistic humility.

Rate performance in the following areas: _________ TOTAL POINTS

Highly Competent
Competent
Target Behavior Needs Improvement (0pts) Exceeds Expectations Superior (3pts)
Meets Expectations (1pt)
(2pts)
 Demonstrates a lack of  Demonstrates effective  Highly effective time  Demonstrates superior
time management time management management during time management
 Demonstrates a lack of during sessions sessions during sessions
knowledge of Rethink  Speaks of Rethink in a  Speaks of Rethink in a  Speaks of Rethink in a
content knowledgeable way knowledgeable way, knowledgeable way,
Professionalism  May overlook or ignore  Remains ethical and identified relevant highly effective in
standards or professional, works with resources identifying relevant
professional codes of integrity, upholds  Remains ethical and resources quickly
conduct, ethics professional and ethical professional, works with  Remains ethical and
 Other: codes of conduct integrity, upholds professional, works with
professional and ethical integrity, upholds
codes of conduct professional and ethical
codes of conduct

Feedback/Notes:
Rate performance in the following areas:
Target Behavior Needs Improvement (0pts)
 Is unable to support
conclusions with facts or
logic, struggles to find basic
solutions
 Considers only a portion of
the available information
 Struggles to consistently
see things from the
parent/caregiver point of
view when making clinical
recommendations or
decisions
Clinical Knowledge  May overlook or ignore
scope of practice
 Other:
Highly Competent
Competent
Exceeds Expectations
Meets Expectations (1pt)
(2pts)
 Demonstrates  Highly competent, gives
competence, gives sound clinical advice
sound clinical advice  Maintains scope of
 Maintains scope of practice
practice  Identifies issues,
 Identifies issues, priorities and
priorities and opportunities, provides a
opportunities rationale for the
 Implements behavior importance of the skill
skills training (BST) being coached and a
techniques, when description of the
applicable behaviors required to
perform the skill
 Generates creative
solutions/strategies
 Implements behavior
skills training (BST)
techniques, when
applicable
_________ TOTAL POINTS
Superior (3pts)
 Superior competence,
gives sound clinical advice
 Maintains scope of practice
 Highly skilled in identifying
issues, priorities and
opportunities, provides a
rationale for the importance
of the skill being coached
and a description of the
behaviors required to
perform the skill
 Highly skilled in generating
innovative, creative
solutions/strategies
 Takes steps to ensure that
clinical recommendations
are in alignment with the
parent/caregiver’s
expectations, messages
and family goals

Feedback/Notes:
Rate performance in the following areas:
Target Behavior Needs Improvement (0pts)
 Does not organize session to
include key content,
summary
 Does not involve
parent/caregiver in problem
solving, or a shared vision
 Does not prioritize top 1-3
needs/skills, and develop an
appropriate course of
action/solutions
 Needs improvement on
creating a timeline for follow-
Coaching Model up and criteria for evaluating
progress for next session
 Needs improvement on
adjusting systems and
approaches to fit
needs/priorities of
parent/caregiver
_________ TOTAL POINTS
Competent Highly Competent
Meets Expectations Exceeds Expectations
(1pt) (2pts)
 Organizes session to  Highly effective in
include key content, organizing session to
summary include key content,
 Involves summary
parent/caregiver in  Highly effective in
problem solving, involving
supports a shared parent/caregiver in
vision, and role plays, problem solving,
collaborates with supporting a shared
parent on prioritizing vision, role playing,
top 1-3 needs/skills, collaborating with parent
and develops an on prioritizing top 1-3
appropriate course of needs/skills, and
action/solutions develops an appropriate
 Creates a timeline for course of
follow-up and criteria action/solutions
for evaluating  Creates a timeline for
progress for next follow-up and criteria for
session evaluating progress for
next session
 Implements behavior skills
training (BST) techniques,
when applicable
Superior (3pts)
 Superior in organizing
session to include key
content, summary
 Superior in involving
parent/caregiver in
problem solving,
supporting a shared
vision, collaborating with
parent on prioritizing top 1-
3 needs/skills, and
develops an appropriate
course of action/solutions
 Creates a timeline for
follow-up and criteria for
evaluating progress for
next session
 Proactively adjusts
systems and approaches
in creative ways that
  Needs improvement on  Proactively adjusts anticipate changing
implementing rehearsal systems and needs/priorities of
opportunities/role playing approaches in creative parent/caregiver
with family member, ways that anticipate  Provides suggestions to
providing applicable changing parents on conducting
examples needs/priorities of rehearsal opportunities-
 Other: parent/caregiver option for video
conferencing, role play
applicable examples, etc.
Feedback/Notes:

Performance Management:

Core Competency Domains Total Points

Effective Communication and Interpersonal Skills, and Cultural Humility
Professionalism, Clinical Knowledge and Coaching Model
Grand Total =
Average Overall Score/rating =