DOCUMENT MODEL E

PSYCHOLOGICAL REPORTS

Guides, document templates, certificates

the psychological reports.
 WELCOME

Aiming to improve productivity, we at ElloCursos Psychology have gathered

the main documents, certificates and reports used by psychologists.
In this way, we hope to contribute to your journey.

All attached models were developed in accordance with the new

CFP Resolution 004/2019.

The professional who acquires the material is free to make any alterations and/or
adjustment.

The information that appears throughout the document in red and uppercase,
They should be replaced by information that the professional must collect.
during the consultation with patients.

You will receive a PDF version and another in Word so that you can
make the necessary changes.

We are available for further clarifications.

HelloCourses Psychology Team

Content

Models of Declarations
Models of Certificates
Multidisciplinary Report Model
Psychological Report Models
Psychosocial Report
Opinion Model
Adult Anamnesis Form
Child Anamnesis Form
Anamnesis Eating Compulsion
Patient record
Therapeutic Contract
Attendance Control
Patient Registration
Attendance Record
Free and Informed Consent Term
Service Provision Contract Models
Models of Online Individual Psychotherapy Contract
Authorization for Online Psychological Assistance for minors under 18 years old

Proposal Template for Establishing Partnerships with Institutions

Model script for Pre-Operative Psychological Evaluation for surgery
bariatric
Referral Models
Sublease Agreement for Room
Letter of request for reimbursement to the Agreement

Receipt Models
Screening Form
Psychological Certificate of Mental Health

Authorization Term for Minors under 18 for psychological consultations

Letter of Request for Accreditation of Agreement
Exit Interview Models
 (INSERT LOGO)

DECLARATION MODEL I

I declare for the proper purposes that Mrs.

is undergoing psychological support, under my care
professionals, attending the sessions (SPECIFY THE DAYS OF
WEEK, SCHEDULES), at the address (DESCRIBE THE ADDRESS OF
SERVICE LOCATION). So far without a forecast date
for the end of the monitoring. (OR SPECIFY THE EXPECTED DATE
FOR THE PURPOSE OF MONITORING

CITY

FULL NAME OF THE PSYCHOLOGIST

Registration number with the CRP

 (INSERT LOGO)

DECLARATION MODEL II

I declare for the proper purposes that it became necessary for Mr. (NAME)
The applicant undergoes psychological follow-up at the outpatient clinic.

THE OFFICE), since (DESCRIBE THE MONTH AND YEAR), under my

professional care.

________________________________,_____of___________of 201_.

NAME

PROFESSIONAL COMPLETION
REGISTER IN CRP
 (INSERT LOGO)

PSYCHOLOGICAL REPORT MODEL I

In light of the Psychological Assessment conducted

Evaluated:
CPF: Age Sexo
Evaluator psychologist:
Registration number at CRP :

Applicant:
Purpose of Assessment:

I certify for the proper purposes that Mr.

presents the following psychological conditions:

and is undergoing psychological counseling to address symptoms consistent with
CID. I declare that this certificate was produced at
based on the Report/Expert Opinion previously issued by me, corresponding to the process of
psychological assessment carried out and that the report will be kept in my
professional files for a minimum period of 05 (five) years, as established in
CFP Resolution 004/2019. I also declare that this document cannot be used
for purposes other than its intended purpose, as it is a confidential and extrajudicial document.

______________________,____of ___________ of 201.

FULL NAME OF THE PROFESSIONAL

CRP /
 (INSERT LOGO)

PSYCHOLOGICAL CERTIFICATE MODEL II

Facing the Evaluation

Psychological assessment completed

Evaluated:

CPF: Age: Sex

Evaluator Psychologist:
Registration Number with the CRP:

Applicant:
Purpose of the Evaluation:

I attest for the purpose of verification to (NAME OF RECIPIENT) that

Mr. (APPLICANT'S NAME) presents symptoms related to (DESCRIBE THE
SYMPTOMS), compatible with the ICD . No moment
needing 3 days away from work activities for follow-up
(OR FOR REST, INDICATE THE REASON). I declare that this certificate has been
produced from a report/statement previously issued by me, corresponding to
psychological evaluation process carried out and the report/assessment issued will be kept
in my professional files for a minimum period of 05 (five) years, as per
established in Resolution CFP 004/2019. I also declare that this document does not
it may be used for purposes different from its intended purpose, as it is a document
confidential and extrajudicial.

______________________,____of ___________ of 201.

FULL NAME OF THE PROFESSIONAL

CRP /
(INSERT LOGO)
 PSYCHOLOGICAL REPORT MODEL I

IDENTIFICATION

Nome
CPF: Age: Sex:
Applicant:
Author
Registration number in the CRP:

Purpose:

2. DESCRIPTION OF THE DEMAND

Mr. sought assistance from the psychology service

(DESCRIBE THE NAME OF THE SERVICE LOCATION. EX: CONSULTATION ROOM
HEALTH) where he reported that (DESCRIBE THE INFORMATION YOU RECEIVED).
In view of the case, a psychological evaluation is necessary for better understanding of the
reported situation, as well as for outlining treatment, if it is necessary.

3. PROCEDURES

Interviews and psychological tests were conducted in meetings of

Hours of duration on alternate days.

PRESENT THE TECHNICAL SCIENTIFIC RESOURCES USED

SPECIFYING THE METHODOLOGICAL THEORETICAL REFERENCE THAT
FOUNDATION OF YOUR ANALYSIS, INTERPRETATION AND CONCLUSION.

CITE THE PEOPLE HEARD IN THE WORK PROCESS

DEVELOPED, THE INFORMATION, NUMBERS OF MEETINGS OR
DURATION TIME.
4. ANALYSIS

In the first sessions, the examined demonstrated (DESCRIBE THE

MAIN CHARACTERISTICS AND EVOLUTION OF THE WORK CARRIED OUT
WITHOUT CORRESPONDING TO A LITERAL DESCRIPTION OF THE SESSIONS

5. CONCLUSION
Through the analyzed data, indications of were verified
(SPECIFY IF THERE WAS REFERRAL, GUIDANCE, AND SUGGESTION)
OF CONTINUITY OF SERVICE)

I declare that this document may not be used for purposes other than
its purpose, as it is a confidential and extrajudicial document.

Note: The psychological report is not intended for

PRODUCE PSYCHOLOGICAL DIAGNOSIS

SIGNATURES FROM THE FIRST TO THE PENULTIMATE PAGE, SIGNING THE

LAST.

______________________,____of ___________ of 201.

FULL NAME OF THE PROFESSIONAL

CRP /

(INSERT LOGO)

MULTIPROFESSIONAL REPORT
1. IDENTIFICATION

name
CPF: Age: Sex:
Applicant:
Author
Registration number in the CRP:

Purpose:

2. DESCRIPTION OF THE DEMAND

.
O Mr. _________________ sought assistance from the service of
psychology (DESCRIBE THE NAME OF THE ATTENDANCE LOCATION. EX:
HEALTH CLINIC) where reported that (DESCRIBE THE INFORMATION THAT
RECEIVED). In view of the case, a psychological assessment is necessary for better
understanding of the reported situation, as well as for outlining the treatment, if this is necessary
necessary.

3. PROCEDURES

Interviews and psychological tests were conducted in X.

meetings of X hours duration on alternate days.

PRESENT THE SCIENTIFIC TECHNICAL RESOURCES USED

SPECIFYING THE THEORETICAL METHODOLOGICAL FRAMEWORK THAT
FOUNDATION OF YOUR ANALYSIS, INTERPRETATION AND CONCLUSION. CITING

THE PEOPLE HEARD IN THE WORK PROCESS DEVELOPED, THE

INFORMATION, MEETING NUMBERS, OR DURATION TIME.

IN CASE OF PROCEDURES OR USE OF EXCLUSIVE TECHNIQUES

IN THE PROFESSION, THESE MUST COME SEPARATE FROM THOSE DESCRIBED BY THEM

OTHER PROFESSIONALS.
4. ANALYSIS

Full name of the Psychologist

The analysis in the multiprofessional report must be

CARRIED OUT SEPARATELY STARTING WITH THE NAME OF
PROFESSIONAL AND THE CATEGORY

In the first sessions, the examined demonstrated (DESCRIBE THE

MAIN CHARACTERISTICS AND EVOLUTION OF THE WORK CARRIED OUT
WITHOUT CORRESPONDING TO A LITERAL DESCRIPTION OF THE SESSIONS).

5. CONCLUSION

Through the analyzed data, evidence of (SPECIFY IF

THERE WASREFERRAL, ORIENTATION E SUGGESTION DE
CONTINUITY OF CARE.

I declare that this document cannot be used for purposes other than its
purpose as it is a confidential and extrajudicial document.

______________________,____of ___________ of 201.

SIGN FROM THE FIRST TO THE SECOND TO LAST PAGE, SIGNING THE
LAST.

FULL NAME OF THE PROFESSIONAL

(INSERT LOGO)

PSYCHOLOGICAL REPORT MODEL I

1. IDENTIFICATION

Name:
CPF: Age: Sex:
Applicant:
author
Registration number with the CRP:

Purpose:

2. DESCRIPTION OF THE DEMAND

The data collected in the first interview were reported by Mr. (NAME
FROM WHOM PROVIDED THE INFORMATION). The information provided by the
description of reported symptoms
observed posture (DESCRIBE THE OBSERVED POSTURE) and the
negative consequences (DESCRIBE THE CONSEQUENCES IN RELATIONSHIPS
SOCIAL AND WORK) indicate that the disorder of (DESCRIBE THE HYPOTHESIS
The diagnosis experienced by Mr. (NAME OF THE EVALUATED) took on proportions
impeding in your life.
Recent studies presented in several publications have indicated that
disorders of (DESCRIBE THE HYPOTHESIS OR DIAGNOSIS) the most common
found in the general population. According to some characteristics, they are
classified as a pathological framework, whose evolution, impairment, and complications
seek medication and/or psychological treatment.
According to the Diagnostic and Statistical Manual of Mental Disorders
especially in the chapter that deals with Disorders of (DESCRIBE THE
DIAGNOSIS), the symptoms presented by Mr. (NAME OF THE EVALUATED)
They characterize a picture compatible with the description of (DESCRIBE THE SYMPTOM)
whose diagnosis referred to in the International Classification of Diseases (ICD) receives the acronym

The evolution of this disorder has typically been chronic.

being exacerbated when the person faces the situations that trigger fear.
 Rarely does this disorder render the affected person incapable; however, in many cases it does.

function of avoiding the situation, it even interferes with social relations and progress
professional, thus compromising the patient.
Psychotherapy has become a therapeutic approach that enables the patient
discover the origin of the symptoms, coping with them, awareness of the conflicts or
fear generators of anxiety and that, depending on the chronicity of the condition, it is possible
at the end of the process, the relief of the suffering experienced by the patient, whether through suppression

total of the focus generating the symptoms, whether by partial suppression of the symptoms, providing

thus, a more satisfactory quality of life than that lived before the process
psychotherapeutic.

3. PROCEDURES

Interviews and the application of psychological tests were held in meetings.

of hours of duration on alternate days.

PRESENT THE SCIENTIFIC TECHNICAL RESOURCES USED

SPECIFYING THE METHODOLOGICAL THEORETICAL FRAMEWORK THAT
FUNDAMENTED YOUR ANALYSIS, INTERPRETATION AND CONCLUSION. CITING
THE PEOPLE HEARD IN THE WORK PROCESS DEVELOPED, THE
INFORMATION, NUMBER OF MEETINGS OR DURATION TIME.

4. ANALYSIS

In the first sessions, the examined person demonstrated (DESCRIBE THE

MAIN CHARACTERISTICS AND EVOLUTION OF THE WORK CARRIED OUT

WITHOUT CORRESPONDING TO A LITERAL DESCRIPTION OF THE SESSIONS. THE

INFORMATION MUST BE SUPPORTED BY FACTS AND THEORIES

RESPECTING THE THEORETICAL FOUNDATION AND THE INSTRUMENTAL
TECHNICIAN USED

5. CONCLUSION
 In light of the data collected in the first interview with Mr. (NAME
OF THE EVALUATED), and considering that the reported symptoms lead the referred Mr. to
experience of subjective sufferings and considering that they are
compromising your personal and professional quality of life, pointing to the
possibility of greater complications, including predisposition to a disorder
depressive, it is concluded, as a preventive therapeutic measure for this evolution towards total remission

or partial symptoms, the urgent need for psychological support.

I also declare that this document cannot be used for purposes
different from its purpose as it is a confidential and extrajudicial document.

NA CONCLUSION IT IS INDICATEDOS REFERRALS E

INTERVENTIONS, DIAGNOSIS, PROGNOSIS AND HYPOTHESIS
DIAGNOSIS, THE EVOLUTION OF THE CASE, GUIDANCE OR SUGGESTION
THERAPEUTIC PROJECT.

City, State, day, month, year.

FULL NAME OF THE PSYCHOLOGIST REGISTRATION NUMBER OF

COUNCIL (CRP)

SIGN THE PAGES FROM THE FIRST TO THE PENULTIMATE, SIGNING THE
LAST

6. BIBLIOGRAPHIC REFERENCES
THE INFORMATION FROM SCIENTIFIC SOURCES OR REFERENCES IS MANDATORY
BIBLIOGRAPHIC, PREFERABLY IN FOOTNOTES.
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 PSYCHOLOGICAL REPORT MODEL II

1. Identification

(insert your patient's name here)

XX years
Single
Purpose: Pre-operative psychological assessment
[Link]

2. Description of the Demand

The description of the demand should be succinct, ignoring details that expose.
Furthermore, the patient must include weight and height, as it will be included in the release analysis.

of health insurance, for example.

Example: The patient sought the resource of surgical intervention, as she lives
with obesity, with recurring and frustrating attempts to control and maintain the
body weight. Currently measures 1.75 cm and weighs 137 kg.

3. Procedure

Present here the tools used. In this case, the sessions and the tests or
other tools used.

Example: 4 sessions were held, one per week. And a test was applied.
psychological and these (...).

4. Analysis

Here belongs the description of the patient's history. It should include how it happened

therapeutic research work that later gave rise to a report. If

used psychological testing in the evaluation. Everything in a succinct manner.
 Example: X therapy sessions were held, where the patient reported
that after several analyses of surgical interventions regarding obesity as well as
its implications.
It was found that he/she has good social and family support, in addition to not having
history of psychiatric disorders and use of psychoactive substances.
You are aware of the entire surgical procedure, as well as its post-operative implications.

surgical. Furthermore, it demonstrated to be in full psychological condition to

face the behavioral changes after the surgery.
At the end of the psychological evaluation, the use of was (necessary or unnecessary)
psychological tests, as (explain about the use or not of tests...).

5. Conclusion

The conclusion should include the evaluation results, a brief summary of the expectation of
patient regarding the surgery and the changes arising from it.

It is concluded that the examinee is in full psychological condition to

to submit to the mentioned surgery, is aware of all the surgical procedures, such as
also of the post-surgical implications and the behavioral changes that may arise
to occur.

I declare that this document may not be used for purposes other than its own.
purpose. It is confidential in nature and is an extrajudicial document.

City, state, date, month, and year.

Full name of the professional

Registration number at CFP

(INSERT LOGO)
 PSYCHOSOCIAL REPORT

[Link]

Name:
Age: RG: CPF:
Date of Birth : Marital status: Sex:
author CRP
Interested:
Subject:

[Link] OF THE DEMAND

Conduct psychological evaluation and behavior assessment of the candidate approved in the process.

selective in relation to the requirements of the position For that purpose, it

used the scientific technical scope of psychology. The demand was constructed as
following steps: individual interview and application of tests.

[Link]

The psychological assessment consisted of the use of the individual Interview technique.
and the application of the following psychological instruments:

[Link]

An interview was conducted, with the evaluated person attentively presenting the questions.
rationalizing and responding to them promptly. It was possible to confirm that it is about
a communicative and sociable person, with a positive conduct, without showing levels of
anxiety, in addition to proper emotional control, with socialization and coexistence
harmonic familiar. The following established characteristics were also measured
to the position as: Perceptual reactivity area, motor area and mental level, balance area
psychic, control high

(reduced), psychomotor domain (adequate), self-confidence (good), resistance to

 frustration (high)
and visual (good), willingness to work (high), resistance to psychophysical fatigue
(good), initiative (good), leadership potential (adequate), ability to cooperate and
working in a group (good), interpersonal relationships (adequate), flexibility of
conduct (adequate), creativity (good), verbal fluency (adequate), phobic signs and
dysrhythmics (absent).
It is worth noting that the candidate was receptive and cooperative at all stages.
described above, as well as having a good level of oral expression in the interview.

Therefore, no type of psychological disturbance was observed at that time.

5. CONCLUSION

According to the evaluation carried out, the candidate is FIT to perform the
activity of .

São Luís, MA____ /____/____

Full name of the professional

Psychologist - CRP -

(INSERT LOGO)
 OPINION

1. IDENTIFICATION
Name:
CPF: Age Sex:
Applicant:
author
Registration Number with the CRP:

Purpose:

DESCRIPTION OF THE DEMAND

DESCRIBE THE INFORMATION, REASONS, AND MOTIVES THAT PRODUCED THE

REQUEST FOR OPINION.

3. ANALYSIS

ANALYZE THE EXPLAINED ISSUE AND ARGUE BASED ON THE

ETHICAL, TECHNICAL, AND CONCEPTUAL FOUNDATIONS OF PSYCHOLOGY.

4. CONCLUSION

PRESENT POSITION ON THE PROBLEM ISSUE OR

QUESTIONED PSYCHOLOGICAL DOCUMENTS.

I declare that this document may not be used for purposes other than its own.
purpose as it is a confidential and extrajudicial document.

City, State, day, month, year

FULL NAME OF THE PSYCHOLOGIST NUMBER OF

COUNCIL REGISTRATION (CRP)

SHE SIGNS FROM THE FIRST TO THE PENULTIMATE PAGE,

LAST
(INSERT LOGO)
 ADULT ANAMNESIS

Date of service: ___/____/_____

1IDENTIFICATION:

Name: ___________________________________________________________________

Age: ______________________

Marital Status

Level of education: __________________________________________________________

Profession:_________________________________________________________

Residence (City/State): __________________________________________________

Contact phone numbers: ______________________________________________________

2SERVICE:

Frequency:

Date/time:

Main Complaint
b)Secondary:

c)Symptoms:

3CURRENT DISEASE HISTORY:

[Link] of the pathology:

b. Frequency:

Intensidade

Previous treatments:

[Link]
4– PERSONAL HISTORY:

a)Childhood:

Routine:

c) Vices:
d)hobbies

e)Work:

5FAMILY HISTORY:

a)Country:
b)Brothers:

c)Spouse:

d)Children:

e) Lar:
f)Previous Pathology (current and past diseases and treatments):

6– PSYCHIATRIC EXAMINATION:

[Link]:

[Link]:

Attitude towards the interviewer:

cooperative

[Link]:
Self-identifying

pathology

Notes:
[Link]:

Surveillance:

Tenacity:

[Link]:

[Link]:

[Link] perception:
 normal

i. Thought:

accelerated

*Content:

obsessions phobias

expansion of the self:

greatness

salvadora ( ) deificação ( ) erótico ( ) de ciúmes ( ) invenção

fantastic_ideas

others:

_____________________________________________________________

retraction of the self

loss

possession

others:

denial of the self:

 hypochondriac ) negação e transformação corporal ( ) autoacusação ( )

guilt

ruína

[Link]:
( ) dysarthrias (poor articulation)
( ) aphasias, verbigeration (repetition of words)
( ) paraphasia (inappropriate use of words with meanings
similar)
neologism
( ) muttering (voice murmured in a low tone)
( ) logorrhea (incessant and uncontrollable flow of words)
( ) para-responses (answers a question with something that has nothing to do)
let's see what was asked

[Link]:

[Link]:
( ) normal ( ) elevated ( ) low mood ( ) sudden breakdown of
tone of humor during the interview
m. Awareness of the current illness:
( ) sim ( ) parcialmente ( ) não

7DIAGNOSTIC HYPOTHESIS:

(INSERT LOGO)

CHILD ANAMNESIS FORM

 I - IDENTIFICATION

1. Name
Age
3. Date of Birth: ___/____/_______

II - FAMILY DATA

01. Father's name:

02. Mother's name:
03. Responsible for the student: ____________________________________________
04. Nº de irmãos / sexo / idade:

05. Position in the family block: ________________________________________________

( ) Married ( ) Separated Child's reaction to the situation:

In case of separation, who does the child live with?

 07. Child: ( ) Biological ( ) Adoptive
Is the child aware of their adoption? ( ) Yes ( ) No

Observation: Child's reaction to the situation

Mark with YES or NO for the alternatives below, use the line
to specify something that is believed to be important.

historical

8.1. Gestação: ( ) Completa ( ) Prematura

8.2. Saúde da mãe durante a gravidez: ( )Doenças ( )Inquietações

8.3. Parto: ( ) Normal ( )Cesariana ( )Induzido

8.4. Amamentação: ( ) Materna ( )Artificial

8.5. Did he/she show delay or problem in speech? ( ) No ( ) Yes

8.6. Difficulties or delays in sphincter control? ( ) No ( ) Yes

8.7. Do you have nighttime enuresis? ( ) No ( ) Yes

Was his/her motor development on time? ( ) No ( ) Yes

Disturbances (nightmares, sleepwalking, agitation, etc.): ( ) No ( ) Yes

8.10. Has special habits (requires the presence of someone, fears, etc.): ( ) N ( ) Y
 Swap letters, phonemes? ( ) N ( ) S
Which ones?

Facts that affected the development of the student (accidents,

operations, traumas etc.) or other occurrences:

[Link] State of the Child

Presents some difficulty:

On the speech: ( ) N ( ) S Which?

In the view: ( ) No ( ) Yes Which one?

 Locomoção: ( ) N ( ) S Qual?

What activities of daily living (ADLs) are they dependent on?

Do you take a shower by yourself? ( ) No ( ) Yes

Do you brush your teeth by yourself? ( ) No ( ) Yes

Do you use the bathroom alone? ( ) No ( ) Yes

Do you need assistance to dress or undress? ( ) No ( ) Yes

10. At what age was potty training achieved?

[Link] Trends:

Does he/she respond to interventions when he/she is disobeying? ( ) No ( ) Yes

Do you have easy crying? ( ) Y ( ) N

Refusing assistance? ( ) No ( ) Yes

Has resistance to touch (caress, affection). ( ) No ( ) Yes

12. Education:

Has the child studied before in another school? Which one: ___________________________

Reason for transfer: _________________________________________________

Have you ever repeated a grade? ( ) No ( ) Yes If yes, which one? ___________________________

Does the child receive any guidance regarding homework? ( ) No ( ) Yes

Who offers? For how long?

13. Do you participate in any of the activities below?

( ) Foreign language course. Which one(s)? _________________________________

Sports modalities. Which ones?

( ) Musical instrument. Which one(s)? _______________________________________

14. Sociability:

Do you make friends easily? Do you adapt easily to your surroundings?

Who are the companions of the child in play?

Group choice:
( ) Mesmo sexo ( ) Sexo oposto ( ) Criança da mesma idade ( ) Criança mais
new
( ) Older child

Preferred distractions:

( ) Televisão ( ) Música ( ) Leitura ( ) Coleção ( ) Computador ( ) Outros.

Which?

Predominant social attitudes: (check)

Obedient ( ) Independent

Aggressive Cooperator

Emotional:

( ) Insurance ( )
Calm Anxious

Happy Emotional ( )
Complaining

Observations:
 (INSERT LOGO)

ANAMNESIS BINGE EATING

Name: ______________________________________________
Data: ____/______/______

I consume a large amount of food, and I have no control over my

Hunger, what do I eat?

This has been happening at least twice a week for the last six
months?
How to not feel hungry?

How too fast?

How do I feel stuffed?

How do I eat alone out of shame for the amount I eat?

Do I feel guilty after eating?

I have feelings of anguish before and after eating?

 PATIENT RECORD

YOUR LOGO

PATIENT FILE

Medical record number: Opening Date:

Full name:

Date of birth: / / Sexo: [ ] M [ ] F

Address:

Phone(s): E-mail

Name, phone number or other type of contact for the responsible person/caregiver (if applicable):

Patient's Doctor(s) (if any): ________________________________________________

Education: Occupation: _______________________

Limitação: [ ] Cognitiva [ ] Locomoção [ ] Visão [ ] Audição [ ] Outras: ________________

Allergy:
 (INSERT LOGO)

THERAPEUTIC CONTRACT

Satisfaction for your interest and decision to invest in your health and quality of life.

This contract you are reading now contains important information about the work that
we are about to develop.

Read it carefully, please!!

After reading this document, if you agree with the policies and procedures
described, I kindly ask that you sign it and return it at our first meeting.
If you have any questions about what is written here, please let me know at the beginning of the
session for us to discuss it. When you sign this document, it
it will represent an agreement between us and will become an integral part of your record where
will all your service records be.

Psychotherapy and its Benefits

Psychotherapy is a process mediated by a specialized professional, aimed at

achieve changes in order to increase the well-being and psychological balance of those who it
search. It is a means that can enhance the person's ability who seeks it to manage
with autonomy and efficiency the challenges that life presents to you.

I work with the approach (Fill in the approach here and briefly talk about its
characteristics) (quickly)
Although each case is particular, in general, the benefits you can expect from
 psychotherapy process are:

Promotion of self-knowledge
Helps find motivation
Improvement in interpersonal relationships
Helps to uncover the origin of certain behaviors
Helps to better articulate feelings
Recovery of self-esteem

Attention: In a psychotherapeutic process, there are no guarantees of results. Each person

respond in a way to the process.

However, we can assert that the expected and frequent results, when the
the patient commits to the process described above.

The appointments will initially last 50 minutes weekly, in the future

Depending on the progress, we can decrease this frequency.

Important:

Eventually during the follow-up you may experience some feelings.

uncomfortable such as anguish, anger, anxiety, and sadness, once psychotherapy will be required
that you bring to the attention of your therapist conflicting situations and experiences where

they may possibly cause you these feelings.

These emotions, when they occur, usually form part of the process that will lead to resolution.
the questions that were addressed. Therefore, understand that often they are
expected indeed.

Duration of the Process

The duration of psychotherapy treatment varies considerably depending on the individual and
of the nature of the issues to be addressed.
It is difficult, if not impossible, to accurately determine the amount of time required.
for the emergence of results. Some factors contribute to this determination
of time are these:
The condition of the problem itself;
How long have you been dealing with the problem?
How is your support network (family, friends)?
Your dedication, discipline, and commitment to monitoring.

The patient is free to decide when to stop the psychotherapy, but of course, I hope
that this decision be made by mutual agreement with me.

Fees

You will be able to make the payment of the service fees in various ways.
different, through single session payments or a package of sessions.

1- Single payment

For the individual payment, the amount for each 50-minute session will be R$
(amount written in full). This payment can be made
directly with me or at the reception, through cash, at the end of each session.

2- Payment by Package

In the case of a package of sessions, you will pay the total amount of R$ ,00
(Amount in full). In this method, you can pay upfront at the beginning of the process,
you divide the value as follows:

● x on the credit card (there may be interest from the provider).

Please write here what your preferred modality is:

If by chance, during the follow-up, you feel that you have difficulties in
remove the fees, I kindly ask you to let me know so that we can find a
best solution.

Cancellations and Delays

The therapeutic process is a professional relationship like any other, therefore, I ask
kindly pay close attention and take care with the commitment regarding your
availability and frequency.

Attention:

The sessions you miss must be paid for, unless you enter into
contact to cancel with at least 24 hours notice.
In case of delays (unless there is a free time after yours), probably
let's finish at the same previously scheduled time.
I also commit completely to our meetings. In the case of any possible
in case of absence or unforeseen circumstances, you will be properly notified in advance, or compensated,

if the notice cannot be given in time.

I will always make every effort to start the sessions at the scheduled time.

Regarding the end of the session, in general, although it should happen around 50
minutes, it may eventually extend a bit, or even happen earlier, everything
It will depend on the day's schedule for the session.

Getting in touch with me

I strive to always be available for my patients, and you can get in touch.
with me through the phone: (Put phone here)
Obviously, I won't always be immediately available, but I will always do the
possible to better serve you.

Confidentiality of information

Don't worry. The confidentiality of the information is fully guaranteed.

The privacy of all communications between a client and a psychologist is protected.
by the Professional Code of Ethics. I can only release information about our
I work with your written authorization. In most situations, I cannot even
confirm to third parties that you are undergoing therapy, unless you agree and me
authorize for that.
However, it is worth emphasizing that there is a situation where, even without your authorization and

consent, I have to release access to the information: in the case of a court order
for involvement in a specific cause.
But don't worry, in this case, you will be notified.

Complaints
If you have any questions or complaints about the process, please feel free.
to talk to me about it so I can answer your questions.
What is the purpose of using this contract?

This contract has two very clear objectives:

Confirm the commitment between us and serve as a tool for instruction
about the therapeutic process.

You can consult him in the future if you have any questions, as well as you can consult me.

ask at any time about any part that has not been clarified.

Welcome!

Your signature below indicates that you have read the information in this document and agree
with your terms.

Client Signature Psychologist's Signature

 (INSERT LOGO)

Attendance Control

NAME: _________________________________________________________________________

START DATE: ___/____/_____

MEETING DATA SIGNATURE

S

10

11

12

13

14

15

16
 17

18

19

20

21

22

23

24

25

26

27

28

29

30

(INSERT LOGO)

PATIENT REGISTRATION FORM

NAME

DATE OF BIRTH

NATIONALITY

MARITAL STATUS

LEVEL OF INSTRUCTION

PROFESSION

CPF
RG

TELEPHONE

E-MAIL

ADDRESS

NEIGHBORHOOD

CITY

STATE

ZIP Code

Do you take medication? If yes, please specify.

FATHER'S NAME

MOTHER'S NAME

(INSERT LOGO)

SERVICE RECORD

NOME

PROJECT/CONTRACT:
(INSERT LOGO)
 FREE AND CLARIFIED CONSENT TERM

By this instrument, which meets legal requirements, the Mr./Ms.

carrier of RG ___________, you will be informed that you will be subjected to a

psychological treatment (psychotherapy) with the psychologist being responsible for
determine the exact moment of the patient's discharge.
The same is aware that all information provided during the therapeutic process is not
they will be disclosed as they will be kept under professional confidentiality.
The patient agrees to make the payment of the amount beforehand.
established at each session held (in-person) or through prior negotiation between the
parts.
Your data and your identity will be kept confidential and your privacy respected,
by the imperative of the code of ethics that governs the professional practice of the Psychologist.

, of of

Patient Signature

Full name of the professional

Professional registration number

(INSERT LOGO)
 SERVICE CONTRACT MODEL MODEL I

Attention:

After the contract is ready, convert it to PDF and only then send it to the
client, thus avoiding possible changes.

Contract template is ideal for lectures, seminars, consulting, workshops.

etc.

O modelo abaixo se trata de um exemplo de contrato para palestra, mas pode ser

SERVICE PROVISION CONTRACT

By this Service Provision Contract, which is made between the parties, on one side, as
CLIENT, ________________, located at Rua ___________, nº ______-
NEIGHBORHOOD___________– CITY____________, STATE___, registered in
CNPJ/MF
item no__________________, state registration _______________ and, on the other side,
as CONTRACTED, ____________________________________, headquartered at
_____________, ZIP Code _______________, registered in the CNPJ/MF under nº

________________, have mutually agreed to the following:

1- The CONTRACTOR agrees to provide the CONTRACTING PARTY (SPECIFY

HIRED SERVICE) with a minimum duration of 75 minutes, PERFORMED
BY THE SR, here referred to as INSTRUCTOR, discussing the topic

__________________
previous proposal sent.

2- For the adjusted services, the CONTRACTOR will pay the amount of R$
__________,00 (write in full) as follows:

R$ XX,XXX.00 (XXXXXXXXX reais) to the CONTRACTED party via bank deposit

 on account number XXXXXX-X, agency XXXX of BANKXXX, on the day XX/XX/XXXX;

First paragraph – The invoice for the total amount described in the item above will be
delivered to the CONTRACTOR on XX/XX/XXXX.

Paragraph two - The CONTRACTING PARTY undertakes to send to the email XXXX the
deposit receipt on the same day the deposit is made.

If the amount is not deposited on the above date, the MINISTRANT will remain
automatically excused from participating in the event.

3- The CONTRACTING PARTY will provide the INSTRUCTOR with all safety guarantees.

people during the fulfillment of their contractual obligation.

4- The CONTRACTOR is obliged to provide the INSTRUCTOR with transportation from

your base to the event location, through the necessary means and previously agreed upon
with the CONTRACTED PARTY. In the case of using taxis or personal vehicles with fuel
payment by the CONTRACTED party, the CONTRACTING party agrees to reimburse
by presenting receipts, within 48 hours.

5- The MINISTER grants the CONTRACTING PARTY the rights of use over its
name, image, and biographical data exclusively for promotion and publicity of the
event referred to in the first clause 30 (thirty) days before and 30 (thirty) days after its
achievement.

6 - The obligations of the CONTRACTING PARTY are:

Do not impose any extra activity on the INSTRUCTOR, except as agreed in the clause.
first
● Provide, if necessary, at your sole responsibility, the permits for the event,
issued by the competent offices, such as the City Hall, Federal Censorship and
copyright entities;
● Maintain silence in the event venue or outside of it, suspending any activity that ...
noise harms the exposure and debate now contracted;
Provide lighting and sound for the INSTRUCTOR during the event.
compatible with the present audience;
Do not record the lecture in audio or video, whether for the internal use of the CONTRACTING PARTY,

for dissemination through any private or public electronic media;

Do not disclose, under any form or pretext, to the print or electronic media or to
third parties not included in the hiring, any information about the remuneration
provided for in this contract

● Provide the INSTRUCTOR with a laptop connected at the location of the lecture.
data show for the use of audiovisual material and, if possible, a lapel microphone
and wireless.

7- The party that violates any clause of this contract will be subject to
payment of the fine of R$ 1,500.00 (One thousand five hundred reais), corrected
monetarily in accordance with the IGPM index or any index that may replace it and interest of
mora in the form of the law, regardless of judicial or extrajudicial notification, in addition to

suffer a competent action for loss and damage.

Paragraph One - Events resulting from force majeure are not included in the infractions.
as a public calamity, social upheaval, impossibility of transport to the location of the
event motivated by road access restrictions, traffic accident or illness
verified by the INSTRUCTOR.

Second Paragraph - In the event that any of the situations provided for in the paragraph occurs
previously, a new date will be set by mutual agreement between the parties, without additional costs

that are not provided for in the fourth clause.

It is the contractor's obligations:

To ensure the CONTRACTING PARTY that the INSTRUCTOR will attend the event and
to perform the work with total commitment and professionalism, except for the
conditions expressed in the First Paragraph;
Provide all the necessary information so that the event can be properly executed.
disclosed, including biographical data, photographs and possibly videos of
Minister

8- The parties jointly choose the central forum of the Capital district of
State of XXXXX to settle any issues arising from this contract.

And, being in agreement, the parties sign this contract in 3 (three) copies of equal content and
for a single purpose, in the presence of 2 (two) competent witnesses signed below.
 City and State, XX of XXXXXXXX of 2019

Contracting Party

CONTRACTED - XXXX

MINISTER

WITNESSES:

Nome

RG:

Name:

(INSERT LOGO)
 SERVICE CONTRACT MODEL MODEL II

1. OF THE PARTIES

1.1. Name of the Psychologist Individual registered in the Individual Taxpayer Registry
CPF/MF under No., General Registration No. ................... SSP/MA, Professional Registration CRP
under the number, with the commercial address xxxx, referred to herein as psychologist/contracted;

1.2. Client, married, Individual registered in the Individual Taxpayer Registry

CPF/MF under No., General Register No., and address, referred to herein as
patient/client.

2. OBJECT: To provide clinical psychological care through meetings

weekly, lasting 50 (fifty) minutes each, by appointment. The
the treatment to be followed will be determined by the psychologist according to the interview

initial/anamnesis, it should be followed by the patient/client and the time of

the duration of it is indefinite, considering that it depends on the evolution of the
patient/client. The psychologist must write down all the data about the work that will
to provide, as broadly and detailed as possible.

3. OF THE EVALUATION

An evaluation consultation will be conducted before the start of the treatment with payment outside.
apart from the amount of R$ 100.00 (one hundred reais).

4. RIGHTS AND OBLIGATIONS OF THE CONTRACTING PARTY

Receive quality care from a qualified professional;

treatment according to the psychologist's recommendation; 4.3: Attend the sessions

on the scheduled date and time;

4.4: Cancel the appointment at least 24 (twenty-four) hours in advance;

4.5 You are obliged to make the payment on the day, at the location, and in the manner specified herein.

contract; 4.6: It is obliged to make the payment for the evaluation consultation;
What is the purpose of using this contract?

This contract has two very clear objectives:

Confirm the commitment between us and serve as a tool for instruction
about the therapeutic process.

You can consult him in the future if you have any questions, as well as you can consult me.

ask at any time about any part that has not been clarified.

Welcome!

Your signature below indicates that you have read the information in this document and agree
with your terms.

Client Signature Psychologist's Signature

 contractual, by express notification to the other party, with a minimum notice of 30
(thirty) days.

In the cases of art. 4.6, termination will be considered at the end of the three sessions in which the
the patient/contractor not showing up, which does not exclude the payment for them.
agreement with art. 6.7.

9. GENERAL PROVISIONS

The breach of any of the clauses related to this contract raises the
accountability of the person responsible, in accordance with the legislation in force.

The contractor is not responsible for objects, values, documents, or any other
property belonging to the Contractor left in the physical space of the Contracted Party.

10. ELECTION FORUM

The parties choose the forum of the District of (city) as the only and exclusive one to resolve
any doubts arising from this contract.

And, by being in agreement, the parties sign this contract in two

equal channels.

City, state, October 8, 2019.

Contracting party: client Hired: psychologist

Witness: Witness:
 SERVICE AGREEMENT

SERVICE CONTRACT MODEL MODEL III

SERVICE PROVISION CONTRACT

IDENTIFICATION OF THE CONTRACTING PARTIES

CONTRATANTE:(Nome do Contratante), (Nacionalidade), (Estado Civil),

(Profession), Identity Card no. (xxx), C.P.F. no. (xxx), residing at
Street (xxx), number (xxx), neighborhood (xxx), ZIP (xxx), City (xxx), in the State (xxx);1

CONTRACTED: (Name of the Contractor), (Nationality), (Marital Status)

(Profession), Identity Card No. (xxx), C.P.F. No. (xxx), residing at
Street (xxx), No. (xxx), Neighborhood (xxx), Zip Code (xxx), City (xxx), in the State (xxx);2

The parties identified above have, between them, justly and rightly agreed to this Contract.

of Service Provision, which will be governed by the following clauses and conditions
price, form and terms of payment described herein.

OF THE OBJECT OF THE CONTRACT

Clause 1. The purpose of this contract is the provision of the service of (xxx)
(Describe the service in detail, with all its specific features, including
technical data that may influence the understanding of the contract, and, if possible,
data resulting from an expert examination involving the situations in which they will be carried out

the service).
OBLIGATIONS OF THE CONTRACTING PARTY

Clause 2. The CONTRACTING PARTY shall provide the CONTRACTED PARTY with all the

necessary information for the performance of the service, specifying the details
necessary for the perfect accomplishment of it, and the way it should be delivered.

Clause 3. The CONTRACTING PARTY must make the payment in the manner and

conditions established in clause 6.

Obligations of the Contractor

Clause 4. It is the duty of the CONTRACTED party to provide the contracting party with a copy of the

this instrument, containing all the specifics of the service provision

hired.

Clause 5. THE CONTRACTOR must provide an Invoice for Services,

regarding the payment(s) made by the CONTRACTOR.

ON PRICE AND PAYMENT TERMS

Clause 6. The present service will be compensated by the amount of R$ (xxx) (value
receipt), regarding the services actually provided, must be paid in cash
or check, or another form of payment in which there is prior agreement by both parties
the parties.3
ON DEFAULT, ON BREACH AND ON PENALTY

Clause 7. In case of default by the CONTRACTOR while

the payment for the service provided should be applied to the value of this instrument,
monetary fine of 2%, late interest of 1% per month, and monetary correction.

Single paragraph. In the event of judicial collection, costs must be added.

procedural and 20% in attorney's fees.

Clause 8. In the event of non-compliance with any of the clauses,

except for item 6 of this instrument, the party that did not comply must pay a fine
10% of the contract value to the other party.

ON UNJUSTIFIED TERMINATION

Clause 9. This instrument may be terminated by either party.

parts, at any time, without any kind of relevant reason, not
however, the other party must be notified in advance in writing, within (xxx)
days.4

Clause 10. If the CONTRACTOR has already made the payment for
service, and even so, request the unjustified termination of this contract, will have the value
from the amount paid refunded, deducting 2% for administrative fees.

Clause 11. If it is the CONTRACTED PARTY who requests the unjustified termination,

he should return the amount related to the services he did not provide to the
CONTRACTOR, added with 2% administrative fees.
ON TIME

Clause 12. The CONTRACTOR undertakes the commitment to carry out the service

within a period of (xxx) months5according to the manner established herein

contract.

THE GENERAL CONDITIONS

Clause 13. It is agreed between the parties that there is a complete lack of bond.
labor relations between the contracting parties, excluding social security obligations and the
social charges, with no agreement between CONTRACTED and CONTRACTING
type of subordination relationship.

Clause 14. Except with the express authorization of the CONTRACTOR, it cannot
Contractor to transfer or subcontract the services provided for in this instrument,
under the risk of immediate termination.

Clause 15. This contract must be registered at the Notary Public.

Titles and Documents.

DO FORUM

Clause 16. To settle any controversies arising from this contract,

the parties choose the jurisdiction of the district of (xxx);
 By being thus agreed and contracted, they hereby execute this instrument,
two copies of equal content, along with 2 (two) witnesses.

, of of 20.

(Local, date and year)

Contracting Party

Hired

(Name, ID and signature of Witness 1)

 (Name, RG and signature of Witness 2)

OBSERVATION

1. If the contracting party is a legal entity, the text must be written as follows:
(Name of the Contractor), based in (xxx), at (xxx) Street, No. (xxx), neighborhood
(xxx), Cep (xxx), in the State of (xxx), registered in the CNPJ under number (xxx), and in the state registry under the

No. (xxx), represented herein by its director (xxx), (Nationality), (Marital Status),
(Profession), Identity Card No. (xxx), CPF No. (xxx), residing at (Street) (xxx),
nº (xxx), bairro (xxx), Cep (xxx), Cidade (xxx), no Estado(xxx).

If the contractor is a legal entity, the text must be written as follows:

CONTRACTED: (Name of the Contracted Party), headquartered at (xxx), on (xxx) Street, No. (xxx), neighborhood

(xxx), Cep (xxx), in the State (xxx), registered with the CNPJ under number (xxx), and in the state registration under the

No. (xxx), hereby represented by its director (xxx), (Nationality), (Marital Status),
(Profession), Identity Card no. (xxx), CPF no. (xxx), residing at (xxx) Street,
nº (xxx), bairro (xxx), Cep (xxx), Cidade (xxx), no Estado(xxx).

Different types or forms of payment can be established, allowing for

contractors or payment to be made weekly, bimonthly, annually, etc.
depending on the characteristics of the service, the amount should be paid as soon as it is performed
the service.

The parties are free to establish this deadline, which will vary according to their interests or the
specific characteristics of the service to be performed.

5. Regarding the deadline for the service to be carried out, it is free for the parties to agree as they wish.
it is convenient for them, which can be in years, months, weeks, etc.
 (INSERT LOGO)

ONLINE INDIVIDUAL PSYCHOTHERAPY CONTRACT MODEL I

[Link]
Each clinical appointment will last approximately 50 minutes, being
carried out at the agreed time, with the psychologist available to the client at that time
period.

[Link]

The psychologist will respect professional confidentiality in order to protect through the

reliability, the intimacy of people, groups or organizations, to which one has access in
professional practice (Code of Ethics of Psychologists, article 9).

[Link] of Psychotherapy

The duration of psychotherapy treatment varies considerably depending on the person and
of the nature of the issues to be addressed.

[Link] and Time

The days and hours of service will be arranged with the client, and may vary from
in accordance with the needs of adjusting the psychologist's schedule and demand for
client.

[Link]
 The payment will be made directly to the psychologist on the agreed dates on the day of
first interview. Any changes to the contract or adjustments can only be made
happen with the knowledge and agreement between the parties.

The session price is R$ for the initial session. The value of the others
sessions will be agreed upon between the parties. Payment will be made through bank transfer or
bank deposit into the account: The payment may be
carried out at each session or monthly with a discount to be agreed.

[Link] or schedule changes

Cancellations must be made at least 12 hours in advance. The psychologist

You should be notified in case of unforeseen events that prevent the client's attendance.
Schedule changes will only be possible when the psychologist is available.

[Link]

Sessions in which the client does not show up will be charged normally. Starting from two
consecutive absences, without notice, during the treatment, the service will be considered
interrupted and the client may lose their preferred time slot.

, of from 20. (Location, date and year)

 Psychologist - CRP

(INSERT LOGO)

ONLINE PSYCHOLOGICAL CARE CONTRACT MODEL II

SERVICE:

sessions. The results

The online service will have a predefined duration of up to
varies according to each person and their participation. The implementation of
proposed activities in the guidance are of utmost importance for the proper progress of the
same.

SCHEDULE:

The appointment lasts 50 minutes and is scheduled at a pre-arranged time.

in advance, once a week, with the Psychologist available to the client at that time
period. As the work is done by appointment, punctuality is
fundamental, it is not possible to extend the time beyond the 50 minutes planned,
even in case of client delays. In cases of psychologist delays, there will be the
compensation beyond the agreed schedule or in a subsequent session. It will not be done and
not contacted the patient after 50 minutes of the session, except in case
rescheduling of appointment or cancellation of session.

MISSING:

They must be notified at least 24 hours in advance. The sessions in which the
Clients who fail to show up or cancel with less than 24 hours notice will be charged.
normally. The smooth progress of the process depends on the frequency and adherence of the client.
to the sessions. In the case of excessive absences (four or more interleaved absences or
consecutive), online psychological guidance should be reconsidered.

CANCELLATIONS OR TIME CHANGES:

In case of cancellations made at least 24 hours in advance, the customer will not incur any charges.
session value. If the absence is reported on the day of the appointment, or not reported, the
the session will be charged normally. These sessions can be rescheduled with the
professional. Schedule changes should be discussed with the psychologist and will be
carried out whenever possible.

TERM:

The termination of services may occur at the customer's choice. If there is

Need for interruption of the sessions, a notice is required one week in advance.
advance notice for a closing session of the orientation to be conducted.

I declare that I am aware of and agree with the above-mentioned information and rules.

City, State of of .

CLIENT OR RESPONSIBLE NAME:

CPF:

PSYCHOLOGIST'S SIGNATURE:
 (INSERT LOGO)

AUTHORIZATION FOR ONLINE PSYCHOLOGICAL ATTENDANCE

FOR CHILDREN UNDER 18

City, day, month and current year.

Me, ,
holder of identity card no. ___________________________________, CPF No.
, residing at the street no. neighborhood

, city____________, state the zip code As a (father / mother /

(legal tutor) I authorize my son/daughter (or ward)
born on the date , in the city
, state to receive online psychological support
the Psychologist registered under number CRP
For this purpose, I must make available for my son/daughter (or ward),
a computer connected to the worldwide network (web) with broadband internet. In addition to,

provide a location with total privacy and respect the professional confidentiality of the sessions
marked with predetermined time and location. I sign below and give my faith in this authorization, which

It will be digitized and sent to the email of the PROFESSIONAL in question.

Sincerely,
 Psychologist's signature

(INSERT LOGO)

Proposal Model for Establishing Partnership with Institutions

This document is a template that you can use to present a proposal for
service/partnership with some institution.

Attention: after it is ready, I do not recommend sending it in WORD to the

possible partner/client. The best is to convert and send in PDF format.

1. Objective:
It is a formalization of the proposal's objective. It is just another formality.

2. General Scope of the Service

This is where you explain, in general terms, what you will offer. This is to delimit.
Well, what will be offered. Generally, when the client/partner accepts, there are small
adaptations and meetings to align expectations.

But this preliminary scope is extremely important for the partner to feel that you
knows what he is doing and has everything planned.

3. General Topics to be Addressed

Here you 'make things tangible', showing the points addressed in your work,
just to give the client a clearer idea of what you are going to do.

4. Generated benefits
The benefits should be for both the partner and some end customer.
 partner. Remember, people will open doors for you, but they expect something in return.

Final Considerations

This is a "template" for you to use, but don't get too tied down. Adapt it to your own.
reality.

INITIAL PROPOSAL MODEL FOR HOLDING A LECTURE

1. OBJECTIVE
The objective of this document is to present a simplified proposal for the implementation of
lecture "Conflict Management in the School Environment" at the Education for Your School
students, parents, and educators.

If there is interest in the work, we will present a more complete version.

necessary.

2. GENERAL SCOPE OF THE SERVICE

The work involves giving a lecture lasting 30 minutes to be

held on a Saturday morning, in the school's premises. The moment involves the
lecture alongside an exhibition of concepts about conflicts in the school environment and ways of
manage them.

The psychologist will act as a facilitator, leading an enriching conversation.

offering small tools that help with emotional health and management of
conflicts within the school environment.

For the realization, a climate-controlled and quiet room is required, with a capacity for
20 people.

3. GENERAL TOPICS OF THE EXPERIENCE MOMENT

What is school conflict?

Identifying your causative sources
Tips for good coexistence at school
4. Generated Benefits
The Education school will be offering an additional service for free to its
students, parents, and educators, generating a perception of greater added value and stimulating the

loyalty also generates customer satisfaction.

Participants will experience moments of learning, learn more about the

own emotions and contribute to the improvement of school coexistence.

5. Comments

This model is a suggestive pre-project. If there is concrete interest, we can

adapt it to meet the school's needs.

City, day, month and year

Full name of the professional

Council registration number
 (INSERT LOGO)

Pre-Operative Psychological Evaluation Model Script for Surgery

bariatric

INTRODUCTION

Here we present a script for the pre-bariatric surgery sessions, highlighting aspects
from the first session. Below, you will find a semi-structured interview script
it is a model of the report.

You can also use the model to structure other sections within this theme.
The purpose is to make the psychotherapist clear about the importance of each one.
two aspects presented here.

THE FIRST SESSION

The first session is very important to explain to the patient how psychology itself works.
can assist you in the weight loss process, image restructuring and dealing with
the behavioral and emotional changes that will come from weight loss.

Most patients have never seen a psychologist and hold unrealistic ideas of
psychology or have you never thought about how a therapeutic process takes place.
 The important thing is to educate the patient about the process as a whole, both of

manifestation of obesity, as well as emotional and behavioral issues

triggered from this condition. The use of tests will be at your discretion.

Structure of the first pre-bariatric session

Session Start

This is the time to make the patient comfortable. Adopt

a posture is friendly and welcoming.
Welcome

Here we have the opportunity to understand who is the

patient and the way their relationship is structured
with the act of eating.

Identification Tell me a
little yours
yes
demand history, and what I also recommend asking social questions.
I brought you here demographics:
here.
So you study at... Work as... Was born
here, was born there... How many
brothers...

Is there someone in the This question is important to know if the patient

family that it has mirrors of behavior and if there are people around
Investigation in front of or those around you who have already undergone bariatric surgery.
are faced the
Clinic obesity?

Intermediate part of the Session

 How are you Question that opens up to addressing anxiety and
feeling expectations regarding the day of the surgery.
Opening in relation to fantasies, beliefs...
for a
expression surgery? Opportunity to talk about the history of others
emotional surgeries.

Here it is revealed whether the patient is aware of the difficulties of

first days, when one day you will be eating everything
Identification and the next day only liquid for a certain period.
of the repertoire How do you think
Opportunity to find out if he knew someone who
related what will be the
having had the surgery and how this person reports.
to the aspects first
practical days?

Closing

Conclude by emphasizing the importance of the pre-bariatric process, to remove

all doubts, understand and respect the team's guidelines
Psychoeducation multidisciplinary and establish a new
a
relationship with food, etc.

(INSERT LOGO)

REFERRAL MODEL I

From:

For: Psychiatry

I am referring (patient's name) for psychiatric evaluation and follow-up.

He began psychological monitoring in (month and year), requiring the
continuation of psychotherapy, however jointly with psychiatric treatment.
I am available for any clarifications and I thank you in advance.
attention given.

Local, day and year.

Full name of the psychologist

Registration number

(INSERT LOGO)

REFERRAL MODEL II

Dear

I refer the patient:

For:

Thank you for your attention, and I await your opinion.

Observation:

Place, day and year.

Full name of the psychologist

Registration number

(INSERT LOGO)

FORWARDING MODEL III

Presented

I am referring the patient

For the service

Reason

Observation:
 Location, day and year.

Full name of the psychologist

Registration number

(INSERT LOGO)

ROOM SUBLEASE AGREEMENT

This document regulates the contractual relationship between XXX with

based in the city of São Luís-MA, hereinafter referred to as "contracted" and of
on the other side, as Contractor.

Name:

CPF: Tel:_____________________
email Address: ______________________

Profession: Professional registration number:_________

CLAUSES:

The contractor is a company whose objective is to provide space and

installations, without exclusivity, intended to provide in a manner
comfortable and optimized the professional activity of the Contractor.
2-Contractor, by signing this instrument, is authorized to use the
available space according to the contracted plan (hourly rate) at the scheduled time
previously scheduled.
3-Contractor declares that its activities developed in the environment do
hired or even outside of this, are fully legal, not violating any norms
civil, criminal, fiscal, or tax established in Brazilian legislation, therefore being
uniquely and exclusively responsible for the development of its activities and for the
filing of the produced documents.
4-OContractor acknowledges that the property subject to this assignment is in perfect condition

state, concerning the furniture, coverings, paintings, floors, decoration and

other installations; as well as that everything is in full operation, and is obliged to

keep it by covering all related provisions, and to return them still

under the same conditions.

City, State, day, month and year.

Contacted Contractor

Witnesses:

Name Name
 (INSERT LOGO)

Letter of request for reimbursement to the Agreement

The purpose of this statement is to validate the psychotherapy sessions by

agreement XXXXX. The patient XXXX, CPF XXX underwent psychological evaluation under
my professional care and presents diagnostic hypothesis of XXX under the Cid XXX.
The patient needs psychological support to understand the moment that
is experiencing, and thus finding coping resources. Periodically
weekly, and is scheduled for 40 (forty) annual sessions, with a total cost of R$ XXX
(XXX) totaling a monthly amount of R$ XXX (XXX), with the initial sessions
to confirm or refute the diagnostic hypothesis. The psychotherapy process will act
in individual, family, and social issues, in order to find alternatives for the
confrontation. Thank you for your attention at this moment.
I am available for any clarifications.

City, date and year.

 Full name of the psychologist

Registration number

(INSERT LOGO)

RECEIPT MODEL I

I, _________________________________________________________
registered with CPF number ___________________ and RG number _ ______
I received from ____________________________________________________
registered under CPF number ____________________ and RG number ______
the importance of R$___________ ________, ( ______
), regarding the payment
for psychological assistance.

City, State of of
 Full name of the professional
Psychologist
Registration number in CRP

(INSERT LOGO)

RECEIPT MODEL II

I received from XXX, CPF XXX, the amount of R$ XXX (XXX), referring to XX sessions.
of psychotherapy, whose individual value for each session is R$ XXX,(XXX). The sessions
took place on the days XXX.

The sessions took place on the days: XXX

City, date and year.

Full name of the psychologist

Registration number
 (INSERT LOGO)

Screening Form

No. ___________

Nome
Sexo: ( ) F ( ) M Idade Date of Birth
Marital Status Schooling _______________________________

School
Affiliation
Address
Neighborhood City
ZIP code Telephone
Profession

Income dependents_number
Spontaneous search
Forwarded by
Service hours:
Reason for the search

Data Trid by

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PSYCHOLOGICAL CERTIFICATE OF MENTAL HEALTH

1. IDENTIFICATION

Name:

Date of birth:

Affiliation:

Applicant:

2. PURPOSE: Admission examination for public competition.

3. PROCEDURE/ANALYSIS:

On October 10, 2019, a psychological evaluation was conducted, with

duration of 50 minutes, using interview techniques and observation.
the subject was submitted to clinical history and psychological examination, with no findings.

no psychological disorder, psychopathological change, or previous symptom. It was

noted that the examinee has an excellent intellectual level, revealing a
coherent speech, with the ability to organize thoughts and judgment
critic. He also showed good attention, good memory, and a normal state of mood and
affection.

4. CONCLUSION

Considering that the examinee presents its functions

preserved mental health and a state of emotional stability. I declare that the same
enjoys perfect mental health, being able to perform her activities
professionals.

City, State, date, month and year.

Full name of the professional

Professional registration number

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AUTHORIZATION TERM FOR MINORS UNDER 18

Psychological Consultations

I, ___________________________________________________________________

holder of ID number __________________, legal guardian of the minor

___________
born on the date / / I am
I consent and authorize the provision of psychological care. Therefore, I take responsibility.
to take all necessary measures to ensure that this is present on the days and
scheduled times and I must justify your absence if that occurs.
I also authorize the collection of information during the services provided for the purpose of

psychological treatment. The data will always be preserved according to the standards of
Code of Ethics of the psychologist.

I am aware that I will need to attend for feedback from the professional at least.
once a month on pre-scheduled date and time.
Therefore, I declare that I am aware of the stated and agree with the issues.
presented in this term.

City, state, date, month and year.

Full name of the professional

Signature of the responsible

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LETTER REQUESTING ACCREDITATION OF AGREEMENT

Dear all,

I would like to express my interest in getting accredited with the Agreement:

.
Name of Applicant:
CPF or CNPJ:
Specialty:
Address of the service location:

Contact phone number:

E-mail:
I am available for further information.

Sincerely,

Applicant's signature

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SEPARATION INTERVIEW MODEL I

Name:

Sector: Cargo: Immediate

Date of Termination date:

admission

Reason for termination:

 Who communicated your departure? And how was the communication made?

What was the work environment like in relation to:

[Link] the colleagues:

[Link] the management:

[Link] the tasks to be developed:

[Link] space, temperature, hygiene, lighting:

[Link] you consider your salary adequate for the tasks performed?
[Link] you like the work you were doing?

[Link] kind of authority was maintained in the department where you worked?

[Link] you participated in courses promoted by the Company? Which ones?

9. Give your opinion on:

Great Good Regular Bad
my

Service received on

Recruitment & Selection ( ) ( ) ( ) ( )

Integration Program

Collaborator ( ) ( ) ( ) ( )
 Training Program ( ) ( ) ( ) ( )

Internal Communication ( ) ( ) ( ) ( )

Service received on ( ) ( ) ( ) ( )

Occupational Safety

Service received at ( ) ( ) ( ) ( )

Benefits Area

Medical Agreement ( ) ( ) ( ) ( )

Pharmacy Agreement ( ) ( ) ( ) ( )

Cafeteria ( ) ( ) ( ) ( )

Comments:

10. What is your opinion about the Company in general (standards, policies, management)?

11. Do you have any suggestions for improvement for the Company?
12. Comments:

Interviewee Interviewer RH

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EXIT INTERVIEWMODEL II
Employee Name:_________________________________________________

Initial Cargo: Final Cargo: ______________________

Immediate Superior: ____________________________________________________

Admission Date: __________________

Reason for Termination

Resignation Request ( ) Dismissed ( ) Transfer to

another unit Agreement

What is the reason for your exit?

Reason given by the immediate supervisor (in the case of termination)

Work Environment
In general, the relationships with your colleagues were:

Great Good ( ) Regulars Ruins

Comment

Working Conditions

How do you rate your physical work environment?

( ) Great ( ) Good ( ) Regular Comment:

What were the resources available for the performance of your work?

How do you rate the Benefits Policy of this Company?

Great Good ( ) Regular Spacious

Comment:

In your opinion, did XXX provide you with professional progress:

Yes No

Comment:

In your position, the activities carried out corresponded to what was assigned to you.

described, when of your admission, promotion or transfer?

In general, do you consider the a
company

Great ( ) Good Regular space

Highlight the strengths of the company:

Point out areas for improvement in the company:

Superiors

How do you classify your relationship with your superior?

( ) Ótima ( ) Boa ( ) Regular Spacious

Comment:
Future Job:

Company:

Cargo:

Remuneration:

Offered advantages:

How did you become aware of the job opening:

Suggestions:

Interviewer's Opinion:
Name and Visa of the Interviewer Name and Visa of the Interviewee

Data: Data: ___________________

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SEPARATION INTERVIEW MODEL III

Name:

Cargo: Sector:

Time of Employment at the Company: Immediate Manager:

Type of termination:

( )Pedido Demissão ( )Demissão sem justa causa ( )outros:

01) On being admitted, were you accompanied during your experience? And during the ...
During your time at the company, did you receive information about your performance?
02) What is your opinion about the work environment in the company? Did you feel
respected and valued by your colleagues and superiors? Was there any
relationship difficulties?

03) Did you have opportunities to develop as a professional? What is your opinion?
about the promotion opportunities in the Company?
01) Did someone inform you of the reason you were dismissed? Do you agree?

02) When leaving the company, what is your feeling? What did you like the most about it?

company? How do you summarize the time you spent here?

Interviewer Comments

Observations:
 Interviewee Interviewer
____/____/_____ Data:____/_____/_____

HR Management Area Management

____/____/_____ Data:____/_____/_____