Escolar Documentos
Profissional Documentos
Cultura Documentos
CRP-03/18339
Nome:____________________________________________________________________
Idade:_____________ Sexo:_______________
Endereço:_________________________________________________________________
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Telefones para Contato:______________________________________________________
Bairro:____________________________ Cidade:________________________________
Religião:___________________________ Escolaridade:___________________________
Filhos (nome, idade e sexo)_________________________________________________
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Profissão:_________________________________________________________________
Est.Civil:___________________
Cônjuge (nome, idade e profissão):_____________________________________________
Queixa principal:___________________________________________________________
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Possibilidade de horários:____________________________________________________
Fez terapia anteriormente? (citar qual e quando)___________________________________
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Expectativas e objetivos do paciente:___________________________________________
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Sintomas apresentados:______________________________________________________
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Parte I – Diagnóstico
Eixo I:____________________________________________________________________
Eixo II:___________________________________________________________________
Eixo III (doenças físicas):____________________________________________________
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Eixo IV (estressores psicossociais):_____________________________________________
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Eixo V (funcionamento global):________________________________________________
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Transtornos psiquiátricos anteriores:____________________________________________
Transtornos psiquiátricos familiares:____________________________________________
Histórico da Queixa
Quando se iniciou:__________________________________________________________
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Eventos traumáticos de vida:__________________________________________________
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Eventos/fatores que precipitam ou agravam crises:_________________________________
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Uso de drogas?_____________________________________________________________
Tentativa de suicídio?_______________________________________________________
Focos de intervenção psicoterápica:_____________________________________________
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Mãe:_____________________________________________________________________
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Pai:______________________________________________________________________
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Irmãos:___________________________________________________________________
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Filhos:____________________________________________________________________
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Outros importantes:_________________________________________________________
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Parte IV – Adolescência
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Parte V – Vida Adulta
Observações:______________________________________________________________
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Profissional:_______________________________________________________________
Encaminhamentos Feitos:____________________________________________________
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):_____________
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Destino do caso:
Alta ( )
Encaminhamento a outra instituição ( ) Qual ________________________________
Abandono ( ) Motivo___________________________________________________
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Encaminhamento a outro profissional ( ) Quem ________________________________
Interrompido ( ) Por que__________________________________________________
Melhoras Obtidas:__________________________________________________________
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