FICHA DE TRIAGEM PARA ATENDIMENTO VIRTUAL

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DADOS DE IDENTIFICAÇÃO:

NOME: ____________________________________________________________________________________
SEXO: M ( ) F( ) OUTRO ( ) RG:____________________________________
DATA DE NASCIMENTO:____/____/______ IDADE_______________________________________
ESCOLARIDADE_______________________ PROFISSÃO ________________________________________
SITUAÇÃO PROFISSIONAL: ( ) EMPREGADO ( ) DESEMPREGADO ( ) CONTRATO DE
TRABALHO SUSPENSO ( ) AUTÔNOMO ( ) COMERCIANTE / MEI
ENDEREÇO: _______________________________________________________________________________
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TELEFONE: ________________________________________________________________________________
EMAIL: _____________________________________________________________________________________
TURNOS DISPONÍVEL PARA ATENDIMENTO: ( ) MATUTINO ( ) VESPERTINO ( )
NOTURNO
ACEITA O ATENDIMENTO ONLINE? ( ) SIM ( ) NÃO

ACESSO AO SERVIÇO DE PSICOLOGIA:

FONTE DE ENCAMINHAMENTO:___________________________________________________
SITUAÇÃO: PRIMEIRA VEZ ( ) RETORNO ( )
PROCEDIMENTO: TRIAGEM ( ) ENCAMINHAMENTO ( )

PROCESSO DE TRIAGEM:

DATA DA TRIAGEM: _________________________________________________________________

RESPONSÁVEL PELA TRIAGEM: _______________________________CRP: ____________________

QUEIXA PRINCIPAL:________________________________________________________________________
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HISTÓRICO DA QUEIXA: ____________________________________________________________________
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 FICHA DE TRIAGEM PARA ATENDIMENTO VIRTUAL

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OBSERVAÇÕES COMPLEMENTARES DO TRIADOR: _______________________________________

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ENCAMINHAMENTO:

SUPERVISOR (A): _____________________________________________________________________________

ESTAGIÁRIO (A): ___________________________________________________________________________

PLANO DE ACOMPANHAMENTO:

( ) 4 SESSÕES INDIVIDUAIS ( ) ACOMPANHAMENTO EM GRUPO

( ) ENCAMINHADO (A) PARA REDE DE APOIO
( ) OUTRO, ESPECIFICAR: