NÚCLEO DE ESTUDOS E PRÁTICAS PSICOLÓGICAS - NEPPSI

Número de Prontuário ________

Supervisão da Triagem: ___/___/___ por ______________
Supervisão do Registro: ___/___/___ por ______________
Liberado para Atendimento: ___/___/___ por ______________
*Uso exclusivo do NEPPSI.

FICHA DO PACIENTE/TRIAGEM

I. DADOS GERAIS

Nome_____________________________________________ RG:________________

Sexo: _______________________ Escolaridade: ___________________________

Formação Profissional: _________________ Ocupação:____________________________

Nascimento ____/____/_____ Idade:_______ Estado civil:__________________________

Mãe_____________________________________________ RG:______________________

Pai ____________________________________________ RG:________________________

Responsável_________________________________________________________________

Endereço __________________________________________________________________

Bairro:_________________ Telefone:_______________ Celular:_____________________

Horário disponível: __________________________________________________________

II. FONTE DE ENCAMINHAMENTO AO NEPPSI.

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III. MOTIVOS DA PROCURA DO AUXÍLIO PSICOLÓGICO.

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IV. DESCRIÇÃO DA DEMANDA

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V. ENCAMINHAMENTO

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Feira de Santana-BA, ______de _____________ de _______.

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Responsável pela triagem