Curso de Psicologia - Atendimento Psicológico
ROTEIRO DE ENTREVISTA PARA ADOLESCENTES
Entrevistador:____________________________________________ Data:___/____/_________
Nome: ________________________________________________________________________
Idade: _________ Data de Nascimento: ___________________ Estado Civil:________________
Profissão: _______________________ Escolaridade: __________________________________
Endereço: _____________________________________________________________________
CEP: ______________________ Cidade/Estado: ______________________________________
Queixa Atual: ___________________________________________________________________
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História Médica e Clínica (considerar história psiquiátrica):
Acompanhamento Médico: (Idade de início e
período(s)):______________________________________________________________________
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Uso de Medicamento(s): (Tempo e período de uso)
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Internação: (Idade, período, motivo)
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Outros: (Cirurgia(s), Acidente (s), etc.)
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Núcleo de Psicologia Aplicada – NPA
Rua Dos Carijós 1034, em frente ao número 1079 – Bairro Centro, CEP: 30.120-060 – Belo Horizonte/MG Telefone: 4009 0950
Curso de Psicologia - Atendimento Psicológico
História Médica e psiquiátrica dos
familiares:_______________________________________________________________________
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Alimentação:_____________________________________________________________________
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Sono:___________________________________________________________________________
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História Social:
Relacionamentos:_________________________________________________________________
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Uso de Redes Sociais: (Freqüência de uso)
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Sexualidade:_____________________________________________________________________
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Lazer:___________________________________________________________________________
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Religião:________________________________________________________________________
História Familiar (incluir genograma): _________________________________________________
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Núcleo de Psicologia Aplicada – NPA
Rua Dos Carijós 1034, em frente ao número 1079 – Bairro Centro, CEP: 30.120-060 – Belo Horizonte/MG Telefone: 4009 0950
Curso de Psicologia - Atendimento Psicológico
Histórico Escolar: ______________________________________________________________
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Histórico Ocupacional: ____________________________________________________________
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Descreva a rotina de um dia habitual da sua vida, do despertar ao recolher.
Manhã: ________________________________________________________________________
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Tarde: __________________________________________________________________________
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Noite: __________________________________________________________________________
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AVALIAÇÃO DO CASO
Impressões do entrevistador
Núcleo de Psicologia Aplicada – NPA
Rua Dos Carijós 1034, em frente ao número 1079 – Bairro Centro, CEP: 30.120-060 – Belo Horizonte/MG Telefone: 4009 0950
Curso de Psicologia - Atendimento Psicológico
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Hipótese(s) Diagnóstica
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
Plano de Intervenção/ Encaminhamento
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Assinatura do (a) Aluno (a) Responsável
Supervisor Responsável: ___________________________________________________________
Núcleo de Psicologia Aplicada – NPA
Rua Dos Carijós 1034, em frente ao número 1079 – Bairro Centro, CEP: 30.120-060 – Belo Horizonte/MG Telefone: 4009 0950
