Psychological cards. Drawing up and filling out a card of primary individual psychological professional consultation The work of a psychologist in compiling a personal card of an employee

Clinical and medical psychologist of health care institutions and other enterprises, in his practical activities anyway, use different kinds documents for the orderliness of work and its proper organization.

In the previous article, we considered the fundamental regulatory legal documents of a psychologist, and here I will reveal to you what you really need in practical work with a client. At the same time, you can download the attached documents in doc format to your computer and use them in your work.

Any activity, as we know, must begin with an order for the main activity in the institution, so we will start with it.

Order: example-sample

This is an order to approve the Regulations on the activities of a clinical / medical psychologist and the maintenance of accounting and reporting forms of documentation, let's consider an approximate example of such an order.

State state-financed organization health care "Name central district hospital" village Name

dated February 17, 2017 No. 128 A "On approval of the Regulations on the activities of a clinical / medical * psychologist of the GBUZ "Name of the Central District Hospital" and the maintenance of accounting and reporting forms of documentation of a medical psychologist"

In order to improve the efficiency of the GBUZ "Name of the Central District Hospital"

I ORDER:

1. Approve:

1.1. Regulations on the activities of a clinical / medical psychologist of the GBUZ "Name of the Central District Hospital", in accordance with Appendix 1 (on 2 pages).

1.2. The form "Consent of the client to the processing of personal data" for the work of a clinical / medical psychologist, according to Appendix 2 (on 1 page).

1.3. The form "Journal of citizens' appeals to a clinical / medical psychologist of the State Budgetary Institution of Health "Name of the Central District Hospital", to record the data of citizens applying to a clinical / medical psychologist, in accordance with Appendix 3 (on 1 page).

1.4. The form “Coding of personal data of a client in the activities of a clinical / medical psychologist of the State Budgetary Institution of Health “Name of the Central District Hospital”, to improve the anonymity of requests and confidentiality of information about clients, in accordance with Appendix 4 (on page 11).

1.5. An individual psychological card of a client of a clinical / medical psychologist of the State Budgetary Institution of Health "Name of the Central District Hospital" to record information about the client, the dynamics of his condition and ongoing psycho-diagnostic, psycho-advisory and psycho-corrective measures, according to Appendix 5 (on 2 pages).

1.6. The form "Journal of advisory work of a clinical / medical psychologist of the GBUZ" Name of the Central District Hospital "for fixing psychological consultations, according to Appendix 6 (on 1 page)

1.7. The form “Journal of psychodiagnostic work of a clinical / medical psychologist of the GBUZ “Name of the Central District Hospital” for fixing psychodiagnostic measures, in accordance with Appendix 7 (on 1 page).

1.8. The form “Diary of individual psycho-correctional work of a clinical / medical psychologist of the State Budgetary Institution of Health “Name of the Central District Hospital” for fixing psycho-correctional measures, in accordance with Appendix 8 (on 1 page).

1.9. The form “Diary of group psycho-correctional work of a clinical / medical psychologist of the State Budgetary Institution of Health “Name of the Central District Hospital” for fixing psycho-correctional measures when working with a group of clients, in accordance with Appendix 9 (on 1 page).

1.10. The form “Report on the activities of a clinical / medical psychologist of the GBUZ “Name of the Central District Hospital” for monthly reporting, in accordance with Appendix 10 (on 1 page).

1.11. Requirements for experimental psychological examination and psychodiagnostic conclusions in the activities of a clinical / medical psychologist of the State Budgetary Institution of Health “Name of the Central District Hospital” and standards for psychocorrectional work, according to Appendix 11 (on 4 pages)

1.12. The procedure for issuing a referral for an experimental psychological examination to a clinical / medical psychologist of the GBUZ "Name of the Central District Hospital", in accordance with Appendix 12 (on 1 page)

1. The control over the execution of the order shall be entrusted to the Deputy Chief Physician for Medical Affairs Surname I. O.

Chief physician I. O. Surname

Familiarized with the order: Surname I.O.

*Note: From the "clinical/medical" type of language, choose the one that best suits your needs. staffing in an organization with job titles. In what follows, I will use these terms as synonyms.

Regulations on the activities of a clinical psychologist GBUZ "Name of the CRH", is, as you already understood, Appendix 1 to the order of the head physician of the GBUZ "Name of the CRH" dated February 17, 2017 No. 128-A and is located on the page "Psychologist: position on activities and job description". We will not consider it separately here.

Consent of the client to the processing of personal data

Appendix 2 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

Heading: "Consent of the client to the processing of personal data"

I, __________ (full name), residing at: _________

_____________________________________,

(name of the identity document, by whom and when issued)

in accordance with the requirements of article 9 federal law dated July 27, 2006 No. 152-FZ “On Personal Data”, of my own free will and in my interest, I agree to the processing GBUZ "Name of the Central District Hospital" (hereinafter referred to as the Institution) of the following your personal data: last name, first name, patronymic, year, month, date of birth, gender, place of residence, including information about registration at the place of residence and place of stay, home number, cell phones, social category of the family.

The processing of my personal data is carried out by the Institution solely for the purpose of providing me medical services and the formation of documents for me as a client of the Institution.

I grant the Institution the right to carry out the following actions with my personal data: collection, systematization, accumulation, storage, clarification, (updating, changing), use, depersonalization, blocking, destruction of personal data to the extent determined by the relevant laws and other legal regulations, using paper and electronic media, in compliance with measures to ensure their protection from unauthorized access.

The institution has the right to carry out mixed (automated and non-automated) processing of my personal data by entering it into an electronic database, including it in the reporting forms provided for by the documents regulating the provision of reporting data (documents).

I am guaranteed the confidentiality of my personal data during their processing and storage, which is carried out no longer than the period provided for by the relevant regulatory legal acts.

This consent is permanent, but I reserve the right to withdraw my consent by means of an appropriate written document.

"___" ______ 20___ ____________ ____________________

(date) (signature) (signature)

Journal of Citizens' Appeal to a Clinical Psychologist

Appendix 3 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

The form of logging citizens' appeals to a medical psychologist of the GBUZ "Name of the Central District Hospital" consists in a table of twelve columns in their headings is displayed:

1. Client code
2. Floor; m/f
3. Date of birth/age
4. Address, phone
5. Social status / place of work
6. Family status
7. Applicant's code
8. Request reason code
9. Issue code/type of case
10. ICD-10 code
11. Dates of repeated calls

Coding of personal data of the client

Appendix 4 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

Encoding of the client's personal data in the activities of a medical and clinical psychologist is necessary. Since in some cases, and even in most cases, at the request of the client, it is necessary to maintain complete anonymity of the survey. To do this, you can provide a kind of encoding. This model is also very convenient for compiling a statistical report.

Code of the client who applied for psychological help

A code is implied, i.e. a serial number under which a client who applied to a medical psychologist was once entered in the "Journal of Citizens' Appeals to a Clinical Psychologist" for the current reporting year. That. any citizen who applied for psychological help has only one entry about himself in this journal in one serial line throughout the year, despite any number of visits to a medical psychologist during the current year.

Client social status code

1. Preschooler.
2. Student of secondary educational institutions.
3. Non-student.
4. Student.
5. Working.
6. Not working.
7. Disability pensioner.
8. Retired by age.
9. Disabled child.
10. An orphan child.
11. A child without parental care.
12. The child is neglected.
13. Orphanage graduate.
14. Disabled person.
15. Unemployed.
16. Forced migrant.
17. BUM.
18. Released from prison.
19. WWII veteran.
20. Combat veteran.

Client family status code

1. Full.
2. Incomplete.
3. Childless.
4. Full of many children.
5. Incomplete with many children.
6. Lonely (after 21).
7. Custodial.
8. Reception.
9. with disabled children.
10. with disabled parents.
11. Single mother.
12. Single father.
13. Underage parents.

Note: the entry may not be limited to using only one code from the corresponding group. If clarifications and additions are necessary, any other suitable code from the group may be set, for example, 02 - single-parent family, 11 - single mother, 13 - minor - 02/11/13.

Code of the person who applied for psychological help

Contact reason codes

Option 1

An ellipsis after the code means that given code can be detailed (using letters or numbers). For example, the code “P” (parent), if necessary, can be specified: “Rm” or “Rd” (similarly, other codes of applicants), and the code “O” of such a reason for applying as learning problems can be detailed as “O1” - problems of mastering the curriculum of elementary school, "O1-M" - problems of mastering mathematics within the framework of elementary school, etc.

Option 2

Codification of problem calls

Codification of problems according to ICD-10

Codes of problems for the medical classification of diseases of the tenth revision "Factors influencing the state of health", "Symptoms, signs and deviations from the norm":

The coding of the client's personal data in the activities of a clinical or medical psychologist of the GBUZ "Name of the Central District Hospital" was developed on the basis of methodological recommendations for the fulfillment of requirements state standard social service population of the Volgograd region "Providing socio-psychological services to citizens in difficult life situation". Volgograd, 2010, Medical classification of diseases of the tenth revision, 1995

Individual psychological map of a psychologist's client

Annex 5 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

An individual psychological card of a client of a medical psychologist of the GBUZ "Name of the Central District Hospital" has the following approximate parameters. I give one of the completed psychological maps as an example.

1. Client code 37,
2. Gender: m/f, f,
3. Date of birth / age 33,
4. Place of residence Art. Name,
5. Social status 06,
6. Marital Status 01,
7. Applicant's code F,
8. Request reason code 12,
9. Issue code/case type 1903,
10. ICD-10 code Z04.8.

February 17, 2017 Psychological counseling.

The client is undergoing inpatient treatment in the therapeutic department of the State Budgetary Institution of Health “Name of the Central District Hospital” due to a deterioration in her somatic condition. The initiative to seek advice from a medical psychologist comes from her attending physician, and not from the client herself. According to the attending physician, the client has anorexia, sleep disturbances, depression and exhaustion of nervous processes.

Appearance the client is untidy, her face is somewhat edematous, undernourished, her speech is quiet, during the consultation she was mostly lying in bed. When asked whether she goes outside or into the corridor for a walk in order to create useful daily physical activity to improve the quality of night sleep, she answers in the affirmative.

Contact is available, oriented in place, time, self. Without difficulty, he correctly names his home address, his date of birth. The client was recommended a psychodiagnostic examination.

February 17, 2017 Psychodiagnostic examination

In relation to the psychodiagnostic examination, there were no resistances on the part of the client. She performed tasks willingly, although her attitude to the examination was indifferent.

Sensorimotor sphere, attention, cognitive sphere.

Methodology: Schulte tables. Lead time.

Table #1 - 93 sec., #2 - 90 sec., #3 - 80 sec., #4 - 91 sec., #5 - 95 sec.

Methodology - testCFIT - R. Cattella.

Only a few completed initial assignments due to client fatigue. From the 1st subtest - 12 tasks - 8 errors. The client cannot fully understand the meaning of solving the presented simple tasks.

Methodology: Simple analogies.

Of the first 10 tasks, 5 were solved incorrectly.

Conclusion: attention is very unstable, performance in dynamics is very low, fatigue/exhaustion of nervous processes is pronounced, the process of thinking is unstable and fragile. The process of operating with simple analogies is disrupted.

At the moment, it is impossible to speak unequivocally about the level of intellectual development and the type of thinking due to rather deep disorders of the somatic state.

Emotional-volitional sphere and personal sphere.

Methodology: Method of color selections (MCV)*.

Methodology: Method of portrait selections (MPV) *.

*Note: The data from the tables can be found in the doc file below.

MCV data: color selection method

Self-regulation is weakened. The sympathetic tone prevails (the process of excitation). Emotional tension is minimal with a tendency to decrease. emotional lability. Weak control over the emotional sphere. The reaction to the emotional load in the direction of disorganization. Positive emotional background. Extraversion (orientation of the personality outside). The performance is reduced. The minimum degree of conflict between anabolic and catabolic tendencies (the desire to accumulate and expend energy). Vegetative balance coefficient = 14/7.

Function Pairs:

1-6. Stress, expressed dissatisfaction, which is caused by a feeling of inferiority and is manifested by restrictive behavior. Dependence of position, uncertainty. increased sensitivity to environmental influences. Expressed control is considered as the only guarantee of self-assertion and upholding of one's positions. The main problems are lack of recognition and increased self-control.

3-1. Dissatisfaction due to the experience of loss or discord in the area of ​​deep attachment. The desire to forget in strenuous activity.

MPV data: portrait selection method

Let's list the most active factors.

hy-- Mixed unstable type of higher nervous activity. Emotionally immature, unstable, emotive type of response. Instability and variability of emotions, demonstrativeness, inconsistency of attitudes, capriciousness, dramatization of existing problems. High probability of developing psychosomatic disorders. When the drives are deformed, there is a high probability of developing deviant behavior.

The need for further psychological research to clarify the personality profile.

The client is recommended to lead a healthy lifestyle, reconsider life priorities, study the information and methodological booklet "Autogenic training".

Clinical psychologist I. O. Surname February 17, 2017

Journal of Consultative Psychology

Appendix 6 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

It consists of six columns, in which it is written:

1. No. p / p
2. Date and time of the event
3. Result

Note:

1. Only one service is recorded in the journal - psychological counseling.
2. In the graph "Appeal"
3. In the graph "The reason for petition"

• what or whom the counselee is complaining about;

*can be coded based on the reasons for the appeal and the type of the client’s appeal, according to the coding of the client’s personal data in the activities of the clinical psychologist of the State Budgetary Institution of Health “Name of the Central District Hospital” (Appendix 3 to the order of the head physician).

1. In the graph "Problem" the following options are written:

1. In the graph "Result" the following options are written:

• the level of client satisfaction (the client is completely satisfied / not satisfied / it is difficult to determine the level of satisfaction / not satisfied with the consultation, etc.).

Journal of psychodiagnostic work of a psychologist

Appendix 7 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

The journal of psychodiagnostic work of a clinical psychologist of the State Budgetary Institution of Health "Name of the Central District Hospital" also consists of six columns, which state:

1. No. p / p
2. Date and time of the event
3. Appeal (primary / repeated)
4. Consulted: client (code), age, gender.
5. Reason for contact or problem
6. Result

It is similar in many ways to the previous magazine.

Note:

1. Only one service is recorded in the journal - psychological diagnostics.
2. In the graph "Appeal" the type of appeal is prescribed: primary or repeated.
3. In the graph "The reason for petition" the following options are written:

• what or whom the diagnosed person complains about;
• what kind of help is waiting (“advise”, “teach”, “influence”, etc.).

*can be coded based on the reasons for the appeal and the type of the client's appeal, according to the coding of the client's personal data in the activities of the medical psychologist of the State Budgetary Institution of Health "Name of the Central District Hospital" (Appendix 3 to the order of the head physician).

1. In the graph "Problem" the following options are written:

• the initial state of the client (“the counselee was in a state of”: anxiety, doubt, uncertainty, despondency, shock, uncertainty, in a vicious circle of conflict, in search of participation, psychological intoxication, aestheticization of personal problems, manipulation, etc. - be sure to indicate in which area) ;

*can be coded based on the type of treatment and / or ICD-10, according to the coding of the client's personal data in the activities of the medical psychologist of the State Budgetary Institution of Health "Name of the Central District Hospital" (Appendix 3 to the order of the head physician).

• the essence of the client’s difficulties (“I want ... but I can’t ...”);
• self-diagnosis (as the client himself explains the reasons for his difficulties).

1. In the graph "Result" the following options are written:

• what is the nature of the existing problem (the problem belongs to the category: acute, requiring immediate help; bears a suicidal risk; requiring the help of other specialists - a psychiatrist, psychotherapist, speech therapist, social worker etc.; not spicy, etc.);
• what has been done (general emotional support provided; support provided decision; a joint analysis and discussion of the life situation and life alternatives; provided information on institutions providing ...; provided information on marital and family relationships; provided information on age characteristics ...; made recommendations in the field professional problems/ family relationships/relationships with children/personal problems; carried out express diagnostics ... etc.);
• general recommendations (the problem requires additional meetings - indicate the date and time of the next consultation; the client must participate in the “…” program; it is necessary to transfer the client to another psychologist-consultant, etc.);
• the level of customer satisfaction (the customer is completely satisfied / not satisfied / it is difficult to determine the level of satisfaction / not satisfied with the diagnosis, etc.).

Diary of individual psycho-correctional work of a psychologist

Appendix 8 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

The diary of individual psycho-correctional work of a medical / clinical psychologist of the GBUZ "Name of the Central District Hospital" consists of six columns with the following content:

1. No. p / p
2. Date and time of the event.
3. Appeal (primary / repeated).
4. Client data: code, age, gender.
5. Techniques and methods of psycho-corrective interventions.
6. Dynamics in the state and behavior of the client.

Note:

1. Only one service is recorded in the journal - psychological correction.
2. In the graph "Appeal" the type of appeal is prescribed: primary or repeated.
3. In the graph "Techniques and methods of psycho-corrective interventions" the psychological methods used in psycho-correctional classes are prescribed accordingly.
4. In the graph "Dynamics in the state and behavior of the client" the results of the psycho-corrective measures taken, recommendations are prescribed.

Diary of group psycho-correctional work of a psychologist

Appendix 9 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

Report on the activities of a psychologist

Appendix 10 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

Report on the results of the activities of the medical / clinical psychologist GBUZ "Name of the Central District Hospital"

for ________________ 201__

Number of working hours: _____________.
Number of psychodiagnostic conclusions by form:
Form 0 ________, Form 1_________, Form 2_________, Form 3_________.

Total for Form 1: ___________.
Medical/Clinical

psychologist _____________ _______________________

(signature) (surname, initials)
"___" _____________ 201__

Requirement for examination and psychodiagnostic conclusions

Appendix 11 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

There are 4 forms of psychodiagnostic conclusions:

Form 0:

1. Conclusion according to the data of a neuropsychological examination, as an examination of increased complexity, requiring a high qualification of a medical psychologist.
2. Conclusion for a comprehensive forensic psychological and psychiatric examination, which is a complete psychodiagnostic examination and the answers of an expert psychologist to the questions posed.

Form 1:

Conclusion according to a complete psychodiagnostic examination. As a rule, it is carried out in connection with the tasks of differential diagnosis, clarifying the degree and depth of disorders of mental activity, identifying intact and disturbed links of the psyche, when solving expert issues.

Form 2:

Conclusion according to a partial examination - sensorimotor, cognitive, or emotional-volitional and personal spheres. As a rule, it is carried out in the clinic of neuroses and in patients with a general somatic profile (clarification of personal characteristics, characteristics of the emotional-volitional sphere).

Form 3:

Conclusion according to the survey data using the MMPI questionnaire with a detailed analysis of the subject's personal profile. It is shown to identify the personal characteristics of the subject, to assess the effectiveness of ongoing psychotherapy, both individual and group.

A set of necessary methods is proposed that should be used in the survey (basic methods) and a set of additional methods that may vary at the discretion of a specialist psychologist.

For the convenience of calculation, the total number of conclusions for the reporting period is reduced to the number of conclusions in form 1.

Given the time required to conduct an examination, analyze the results and write a conclusion, the normative workload of a medical psychologist can be 16 conclusions in form 1 per month for one rate of a medical psychologist (with a 36-hour working week) - in a hospital. In the outpatient service 20 conclusions in form 1 per month. At the end of the month, the psychologist submits a report on his work ( Annex 9).

Below are requirements for experimental psychological examination and conclusions.

Requirements for examination and conclusions

To the conclusion in form 1(total labor costs for 1 conclusion 9-10 hours):

To the conclusion in form 2(total labor costs for 1 conclusion 5-6 hours): Study of one or two of the indicated areas.

All basic methods for examining a certain mental sphere, plus 2-3 of the additional ones (at the discretion of the psychologist).

Two opinions in form 2 are equated to one opinion in form 1.

To the conclusion in form 3(total labor costs 3-4 hours):

Questionnaire MMRI with the interpretation of a personal profile.

Three conclusions in form 3 are equated to one conclusion in form 1.

To the conclusion in the form 0(total labor costs 20-25 hours):

One Form 0 opinion is equivalent to three Form 1 opinions in a hospital, and two Form 1 opinions in an outpatient service.

Note:

1. In the study of patients: with reduced intelligence; defects in hearing, vision; with a general poor somatic condition, a decrease in the number of presented methods is allowed. Similarly - when examining patients in an outpatient service with a lack of time.
2. The list of additional methods cannot be given completely due to their large number.
3. In the psychological study of children, methods specific to a given contingent of subjects are included.

Standards of psycho-correctional work of a medical psychologist:

A. Group psycho-correctional work

Any group work requires careful theoretical and methodological preparation, analysis of previous lessons and the behavior of each of its participants, assessment of the dynamics in the state of each member of the group. Given these conditions, it is recommended to conduct two group sessions per day at the rate of a medical psychologist, including the following steps:

1. room preparation, teaching aids, formulation of the task, drawing up a scenario for a group lesson - 30 minutes.
2. Introduction and “warm-up” (warm-up) - First stage group work - 15-20 minutes.
3. Implementation of the main tasks - the main stage of the group's work - 60 minutes.
4. Summing up the group lesson - the final stage - 15 minutes.
5. Documentary registration of the conducted group psycho-correctional / psychotherapeutic session (filling in a formalized form of a group session or a description of the group session according to the scheme in the diary of group psycho-correctional work - Appendix 8) - 45 minutes.

B. Individual psycho-correctional work

In one working day, a psychologist can conduct no more than four individual psycho-correctional sessions, that is, 90 minutes are allotted for one session, which include:

1. Preparation for the lesson (reading special literature, talking with the attending physician, studying the medical history, and in case of repeated classes - analyzing previous meetings) - 15 minutes.
2. Lesson - 60 minutes.
3. A record of the lesson in the medical history, register and (or) in a special diary of individual psycho-correctional work ( Appendix 7) - 15 minutes.

The procedure for issuing a referral for an experimental psychological examination to a psychologist

Appendix 12 to the order of the chief physician of the GBUZ "Name of the Central District Hospital"

The referral contains the following information about the patient:

1. Name of the patient.
2. Year of birth.
3. Primary diagnosis (or diagnostic versions).
4. Research task.

Options

A. Differential diagnosis (with the identification of a pathopsychological symptom complex inherent in a particular mental illness);

B. Clarification of the degree of severity (depth) of the disorders present in the subject (decrease in intelligence, depth of emotional-volitional disorders, personality changes, etc.);

C. Identification of the structure of disturbed and intact links of mental activity;

D. Identification of installation tendencies (simulation, dissimulation, aggravation, sursimulation, metasimulation);

D. Evaluation of the dynamics of neuropsychiatric disorders;

E. Diagnostics of the level of mental development for the choice of ways of training and retraining.

Purpose of the study

Options: VVK; MSEC; SSPE; KSPPE; KEK; school expertise; assessment of the effectiveness of therapy; choice of ways of therapy and correction.

Attending doctor

____________ _____________________

signature surname, initials

"___" ____________ 201__

Related videos

Clinical and Medical Psychology

Well, that's all, good luck in your practical work as a psychologist! I hope my information will be of great benefit to you and will facilitate your work.

A psychological consultation card is issued in the event of a set of measures (diagnostics, conversations, consultations, etc.) at the request of a parent, teacher, administration or child. The map is compact, which allows you to summarize and analyze all the diagnostic and corrective work carried out.

1. Full name of the applicant ( parent, teacher)

2. Problem ( who/what is complaining about)

3. Anamnesis ( living conditions, features of development and education)

5. Personal characteristics of the applicant

6. Personal characteristics of the child ( from observations)

7. Psychodiagnostics ( conducted methods, their results)

10. Consultations with other specialists ( to whom it is directed, the result)

11. Full name of consultant

12. Dates of work ( taking into account psychodiagnostics, conversations, etc.)

Reporting documentation of a psychologist

According to the reporting, the administration judges the work of the psychologist as a whole. And if reporting is not kept, all types of work of a psychologist are not noted, the administration believes that the psychologist does not work much and, in general, “it is not clear what he is doing there ?!” Therefore, it is necessary, it is necessary to show the director and the administration that the psychologist is working tirelessly and not wiping sweat from his forehead.
It makes sense to maintain two types of reporting documentation - current(for the accepted reporting period - month) and final(per academic year). The current analysis of the work performed can be reflected directly in the registration part at the end of each month.

The structure of the monthly report completely coincides with the structure of the annual (final) report, so the preparation of the final report is not difficult. It is only necessary to summarize each unit of work performed for all months and enter the amount received in the appropriate section of the annual report.

Based on the results of statistical reports for each month and year, it is possible to write relevant analytical reports.

Such documentation of a teacher-psychologist ( special psychologist) of an educational institution clearly demonstrates the content of the diagnostic and correctional development work.

The units of activity should be considered a report on the diagnostic work carried out, among which primary (deep) examination, dynamic and final individual examinations, conclusion according to group forms of diagnostic work, as well as report on intermediate and final results individual and group correctional and developmental work.

analytical report for the corresponding period of the psychologist's activity, the annual report on the work carried out should be considered. In our opinion, the monthly report should be presented only in statistical form.

We do not consider it necessary for a psychologist to necessarily use rigid structured reporting schemes.

Reporting documentation (conclusions on the results of the survey, analytical reports) are "external" documents (as opposed to the direct protocol of the survey, which should be considered exclusively "internal", which is an absolutely confidential document of a specialist), to which specialists who have direct relationship with the psychologist's client.

Form 10.

Statistical annual report

(mandatory form)

Approved:

"___" ____________2008

Director: __________

STATISTICAL PROGRESS REPORT
FOR 20/20 SCHOOL YEAR

Educational institution

Territory________________________________

The number of students (pupils) in the educational institution __________________

including the levels of education:

Primary School (junior group)_________________

middle step ( middle group)__________________

senior level ( senior group)___________________

(preparatory group) ____________

population teaching staff in OS _________________

I. PERSONAL DATA

P. VOLUME INDICATORS OF THE PSYCHOLOGIST'S WORK

III. METHODOLOGICAL SUPPORT

1. LIST OF METHODS USED

2. LIST OF USED CORRECTION AND DEVELOPMENT AND PREVENTIVE PROGRAMS

Report prepared

(Name of the psychologist or head of the PS)

Signature

"__" ____________ 200__

(Date of the report)

ANALYTICAL REPORT ON THE WORK OF A PSYCHOLOGIST TEACHER

1. Purpose, object, subject of research.
   Building a hypothesis.
   The choice of psychodiagnostic methods.
   Developer, diagnostician
2. Presentation of research results.
3. Analysis of the received data.
4. Conclusions and recommendations.

Analytical report of the teacher-psychologist of the preschool educational institution

Full name of the teacher-psychologist ___________________________

OU ______________________________________________

Target: _____________________________________________________________

Tasks:___________________________________________________________

__________________________________________________________________

Qualitative and quantitative analysis by areas of activity:

The results of the diagnosis of children in preschool

Accounting table psychological readiness children to school

Number of children in preparatory groups preschool educational institution (according to the list) _________

Table of records of children's adaptation to kindergarten

The number of newly enrolled children in groups (according to the list) _____________

Table of accounting for correctional and developmental work

Consulting work accounting table

Table of accounting for psychoprophylactic work

Table of accounting for educational work

ANALYSIS OF THE ACTIVITIES OF THE PSYCHOLOGICAL SERVICE

_____________________________ for ________________ account. Name ___________________________________

When a client visits a psychotherapist, every self-respecting specialist keeps a history of working with this person. Of course, this is not a "case history" and not an "instruction for use", but still it gives a lot of information to me. In particular, about how the process is going (and whether it is going at all) or where to “direct the skis”, for example.

If you are interested, you can read such a Client Map performed by a Gestalt psychologist and get an idea of ​​what we fix when we sit with a smart look in front of our clients with pens and notepads or voice recorders.

I recently wrote a client report template for the Psychological Studio PersonaGrata. With this template, you can easily structure your thoughts about current or completed work with a client. The template will help to present a case for supervision or intervision, and simply support the therapist in thinking about the client. If the therapist takes notes (and he should) then the template can be used as a basis. Since many students of Gestalt institutes read me, I thought that the text could be useful here as well. The template is written in a comic form: not out of disrespect for human suffering, but only to soften the clerical style.

Info: full name, age, marital and social status, special information (transgender, expat, retired cosmonaut, refugee, alien, former prisoner, retired killer, has a psychiatric (somatic) diagnosis: what kind, history of the course of the disease, is it observed ...) , which may be important.

Background and History: what historically brought the client to you? Everything was fine and suddenly insomnia began to torment. Or everything was always bad, and a friend advised me to apply. Or he fell, woke up, plaster, finally decided to deal with memory loss and the passion to smoke araucaria stalks (as he smokes araucaria, so memory loss and then finds himself in an unseemly form: tired!)

Complaint: what exactly did the client come with. Wants to change the planet, gender, age, overeats sweet corals, (quit smoking araucaria). Confused, doesn't know where to start. Depression due to the fact that sweet corals do not grow on our planet. The trauma of losing a beloved Snufkin. Loneliness: there is no one to discuss issues that concern aliens. I want to prepare for resettlement to Pluto, this is alarming, and PTSD after the previous resettlement from the planet Plyuk does not give rest: poor sleep, no appetite, I don’t even want sweet corals (…)

Request: What exactly did you agree to work with? With a study of the origin of the desire to change age (obviously, you discussed with the client that this need cannot be primary); with increasing awareness of true needs; seeking support resources; with the question “what need do I eat corals and smoke araucaria?”; with the consequences of the trauma of relocation from Pluka?…

Process analysis: How did you start, where, how and through what did you come? We investigated the desire to change age (smoke araucaria, eat corals), found anxiety under it. They explored it, found dissatisfaction with themselves. Explored dissatisfaction, found narcissistic trauma. They remembered how mother fed her younger brother with sweet corals, and said: “But you, Valproj, are not supposed to, your proboscis has not turned blue yet, but you are already eleven!” (...) We worked through the narcissistic trauma, returned back, found that we still want to change our age, however, the motivation has changed: in order to become a five-year-old again, joyfully take away sweet corals from my younger brother and not bathe. Or: they changed their mind about changing their age, realized an acute desire to change the planet and calm down on this for a while. (…) We worked with the complaint “I want to change my age”. We formed a request “to understand how such a need arose”. We worked with fusion (I don’t know why, but I want to) and introjection (it’s always better to be young!). And with the merger with the introject (Yes, I'm sure it's better to be young, but what?). We worked with the body (what I feel when I say that I want to change my age, etc.), with (dis)trust in the therapist (All therapists work for money, otherwise they don’t give a damn about us), came out with distrust and distancing serving him. We studied ways to distance the client using devaluation and negative projection. When the client-therapeutic contact was established, it became possible to recall the early trauma. Experienced trauma, assimilated the experience. (...) Then we looked at what is behind the desire to change age. It turned out that there was a fantasy “to fix everything”, “to get a good mother”.

(...) 4 sessions grieved about the fact that there would be no good mother. They accepted their limitations, defects, imperfections. The therapist admitted that he also suffered from this, which further strengthened the relationship. They suddenly realized that they didn’t want to change their age anymore. I want to go to Venus, my younger brother and his family live there (yes, the client forgave his brother). I wanted to settle down, set up a coral plantation on Venus. Get a goat, name it Snufkin, after the wombat that the client had as a child.

Completion of therapy: what the client said about how his life has changed. What the tests said. For example, he himself says that he began to sleep better, his appetite appeared, attachment to his relatives returned. Forgotten idea to change the age. There are other desires. (...) What the tests say: depression decreased by 38% (Pupkind's questionnaire), anxiety by 60% (Vaskind's questionnaire). Test for codependency Sigitova-Gaverdovskaya: the indicator is 20% lower. A decision was made to interrupt therapy until such a need arises. A control meeting was scheduled in a year with control testing on the specified tests.

Therapeutic Growth: What were the most common requests for supervision with this client? What did the therapist learn from this therapy? What areas of growth have you discovered in yourself?

FROM Best wishes, Natalia!

Topic: Preparation and conduct of psychological

Consulting, its stages and procedures

Plan

1. How to prepare for psychological counseling

2. How psychological counseling is carried out

3. The main stages of psychological counseling

4. Psychological counseling procedures

Exercises

Practical tasks

How to Prepare for Psychological Counseling

Preparation for psychological counseling includes the solution of a number of general and particular issues, with general questions relating to counseling in general, and particular questions relating to the reception of clients in psychological counseling.

Some of the most common issues in preparing for counseling include:

1. Choice of premises and equipment of the place for consultations. The equipment of the room includes providing it with chairs or chairs that are comfortable for the client and the consultant, preferably rotating, a coffee table.

Chairs instead of armchairs are used if the time of consultation, i.e. joint work psychologist-consultant with a client is relatively small and during the consultation it is important to carefully monitor non-verbal behavior client. Preference is given to chairs when the counseling procedure is sufficiently long in time, and during the consultation it is necessary to create and maintain an informal atmosphere for communication between the psychologist-consultant and the client. In addition to furniture, in a psychological consultation it is desirable to have audio and video equipment in case there is a need to keep, listen to or view any recordings.

2. Supply of consultation with paper, copying equipment, a computer, everything necessary for fixing the course of the consultation and its results, duplicating documentation, etc. In addition, in a psychological consultation it is desirable to have a calculator, which, in particular, may be needed when quantitatively processing the results of a client's psychological testing.

3. Equipping the place of consultation with the necessary documentation and providing the means of storing it, and in particular, a registration book, a client card file and a safe (a safe is also needed to store files with confidential information when using a computer). The registration log, the sample form of which is given in table 2 below, records general data on clients and consultations. The card file (Table 3) contains personal data about each client obtained during the consultation as a result of questioning the client by a counseling psychologist. This data should be detailed enough to be able to form an idea about the client and the nature of his problem. A safe or a computer is needed so that they can store a card file of clients and other non-disclosure data.

table 2

Sample log worksheet form

psychological consultation

Table 3

Approximate form of an individual customer card

4. Acquisition for consultation of a minimum of special, including psychological, literature. This literature, firstly, is needed so that the consultant psychologist can get the necessary information for himself and for the client directly from the primary sources in time and quickly enough, and secondly, in order to give the client the necessary literature for temporary use for the purpose of self-education . In addition, it is recommended to purchase for psychological counseling a number of the most useful popular publications on practical psychology, which the client would have the opportunity to receive here, and to receive psychological counseling for an additional fee and his own, permanent use on the recommendation of a counseling psychologist.

The design of the consultation room is made in such a way that the client feels comfortable in it. It is desirable that the premises for psychological counseling resemble something between an office and a home (a workroom, an apartment, a living room).

Special issues in the preparation of psychological counseling include the following:

Preliminary acquaintance of the psychologist-consultant with the client according to the data about him, which are available in the registration journal and in the file cabinet. An individual card for each client is usually filled out for the first time when the client goes to psychological counseling and comes to an appointment with a specific consultant. An entry in the client's individual card is made by the psychologist-consultant who conducts the consultation. He is also responsible for the confidentiality of information received from the client.

Preparation of materials and equipment that may be needed during the psychological consultation.

Obtaining additional information about the client from various available sources - such as may be needed during counseling.

Development of a plan for conducting a consultation, taking into account the individual characteristics of the client and the problem that worries him.

date of consultation

Full Name _____________________________________

Age..17 years old

School №45

Class 11-B

the date 18.11.04

Health status:

a) healthy +, b) functional deviations, c) chronic diseases

The conclusion of the teenage doctor: Practically healthy. He is not registered with the dispensary.

II. Information about the world of professions:

a) full +

b) insufficient

c) missing

III. Having a professional plan:

Profession: nurse educational institution Donetsk medical school

IV. Formation of a professional plan:

a) formed +

b) partially formed

c) not formed

V. Awareness of the choice of profession. The profession was chosen consciously, independently.

VI. leading motives. Acquisition of knowledge about clinical manifestations, preventive measures and methods of treatment of diseases. Learn to apply the acquired knowledge in practice in order to provide medical care sick people.

VII. Information from the "Optant Questionnaire":

Favorite activities: travelling.

preferred professions: doctor, nurse, programmer.

work experience: no.

the success of training in the disciplines:

natural: excellent precise: excellent

Humanitarian: good................... Labor: excellent

VIII. Interests and aptitudes of DCO:P 3 T 4 H 5 3 5 X 2

Map of interests:

IX. Communicative and organizational inclinations: Kk - 1,2,3,4,6;

K0 - 1.2, 3.4, 5.

X. Expression of professional interests and inclinations:

a) are pronounced (in what field of activity?) in medicine

b) not expressed

XI. Features of behavior - communication, tolerance, organizational skills.

XII. Conclusion of the professional consultant:

a) optant does not need in-depth professional consultation (professional plan is justified, professional plan formed during the consultation process)

b) the optant needs in-depth professional consultation

field of activity, profession work in the field of medicine: doctor, nurse; psychologist.

Ways of professionalization medical school, medical institute; psychology faculty.

Fallback professional choice teacher.

Homework visit day open doors in universities, to get acquainted with the work of health workers in practice, for example, during the holidays, get a job as a nurse's assistant in a hospital.

Contraindicated areas of activity ... work that requires physical exertion.

Psychologist-professional consultant:..Litvinenko O.O.

Conclusion: The optant is well informed in the world of professions, a professional plan has been formed, a profession has been chosen, ways to obtain it have been thought out, there is confidence in the correctness of the choice. The choice of a profession is realized, which can be seen from the questionnaire of the optant - the plan corresponds to cognitive interests, professional orientation, individual psychological characteristics of the personality, adequate motives for choosing a profession are indicated and realized.

In the analysis of the study conducted using a differential diagnostic questionnaire, the subject's orientation to professions in which the subject of labor is a person is clearly traced, which also corresponds to the correct choice of profession.

Analyzing the data obtained during the diagnosis of cognitive interests according to the "Map of Interests" developed by A.E. Golomshtok can note a pronounced interest in medicine, mathematics (+6), as well as in physics, chemistry, technology and law (+5), and in such areas as metal and woodworking, geography, geology, transport, aviation, foreign languages and performing arts interest is denied (-6).

To assess the potential of the individual, using a questionnaire of communicative and organizational inclinations, the result (4 points) was obtained, indicating that the optant belongs to a group with a high level of manifestation of communicative and organizational inclinations, who do not get lost in a new environment, quickly find friends, constantly strive to expand circle of their acquaintances, help relatives, friends, show initiative in communication, are able to make an independent decision in a difficult situation. These qualities correspond to the chosen profession.

Therefore, the intentions of the optant must be supported, approved, and possibly additionally informed about the available educational institutions, admission rules. As homework It should be noted the importance of learning foreign languages.

It is also necessary to develop a fallback option - in my opinion, this is the profession of a psychologist or teacher. And define the area professional contraindications- these are professions associated with physical activity; not recommended areas - performing arts, construction, metallurgy.