Nome:________________________________________________________________

Idade:_______________ Sexo:_________________Telefone:____________________
Endereço:______________________________________________________________
Bairro:____________________________  Cidade:_____________________________
Religião:___________________________ Escolaridade: ________________________
Filhos (nome, idade e sexo): _______________________________________________
Profissão:______________________________________________________________
Est.Civil: __________________________ Data de Nascimento:___________________
Cônjuge:_______________________________________________________________
Queixa principal:________________________________________________________
Possibilidade de horários:_________________________________________________
Fez terapia anteriormente? (citar qual e quando) _______________________________
Expectativas e objetivos do paciente: ________________________________________
Sintomas apresentados: ___________________________________________________

Parte I – Diagnóstico
Eixo I:_________________________________________________________________
Eixo II:________________________________________________________________
Eixo III (doenças físicas): _________________________________________________
Eixo IV (estressores psicossociais): _________________________________________
Eixo V (funcionamento global): ____________________________________________
Conceituação Psicológica do Caso: _________________________________________
______________________________________________________________________
Transtornos psiquiátricos anteriores:_________________________________________
Transtornos psiquiátricos familiares: ________________________________________
______________________________________________________________________
Doenças Importantes que teve: _____________________________________________
______________________________________________________________________
Medicação que está tomando: ______________________________________________
Medicação alternativa (chás, compostos, etc.) _________________________________
______________________________________________________________________
Aplicação de Testes? Se sim, qual e resultado: ________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Histórico da Queixa
Quando se iniciou:_______________________________________________________
______________________________________________________________________
______________________________________________________________________
Eventos traumáticos de vida:_______________________________________________
______________________________________________________________________
______________________________________________________________________
Eventos/fatores que precipitam ou agravam crises:______________________________
______________________________________________________________________
______________________________________________________________________
Uso de drogas?__________________________________________________________
Tentativa de suicídio?_____________________________________________________
Focos de intervenção psicoterápica:__________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Parte II – Relacionamentos Importantes

Mãe:__________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Pai:___________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Irmãos:________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Filhos:_________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Outros importantes:______________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Observações sobre dinâmica familiar atual:___________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Parte III – Infância

Gravidez (planejada ou não), parto, intercorrências
obstétricas:_____________________________________________________________
______________________________________________________________________
Amamentação:__________________________________________________________
______________________________________________________________________
______________________________________________________________________
Estressores na infância, crises:______________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Outros transtornos infantis (sono, alimentação, psicomotor, gagueira, tiques,
sonambulismo, aprendizagem): _____________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Outros comentários:______________________________________________________
______________________________________________________________________
______________________________________________________________________
 Parte IV – Adolescência
Experiências afetivas marcantes:____________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Experiências sexuais marcantes:____________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Independência/ primeiros empregos: ________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Círculo de amizades:_____________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Parte V – Vida Adulta

Relacionamento com parceiro:______________________________________________
______________________________________________________________________
______________________________________________________________________
Vida Sexual Atual:_______________________________________________________
______________________________________________________________________
______________________________________________________________________
Situação Financeira:______________________________________________________
______________________________________________________________________
______________________________________________________________________
Abortos espontâneos/provocados:___________________________________________
Apoio Social disponível: __________________________________________________
______________________________________________________________________
Outros transtornos atuais (sono, alimentação, tiques,etc.): ________________________
______________________________________________________________________
Principais lazeres, vida social:______________________________________________
______________________________________________________________________
______________________________________________________________________

Parte VI – Observação e Linguagem Não verbal do Paciente

Observações:____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Parte VII – Atendimentos Prestados

Profissional:____________________________________________________________
Encaminhamentos Feitos:_________________________________________________
______________________________________________________________________
______________________________________________________________________
Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):__________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Destino do caso:
( ) Alta ( ) Encaminhamento a outra instituição Qual?_______________________
( ) Abandono Motivo____________________________________________________
( ) Encaminhamento a outro profissional.Quem? ______________________________
( ) Interrompido.Por quê?_________________________________________________
Melhoras Obtidas:_______________________________________________________
______________________________________________________________________
______________________________________________________________________
Outras Observações Importantes:___________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Natal/RN, ____de ________de 20___.

______________________________________________
Responsável/Paciente

______________________________________________
Edyla Tarciane Palhares de Araújo
Psicóloga
CRP 17/5693