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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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EVERALDO DE CARVALHO 2022
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Doenças físicas:____________________________________________________________
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Estressores psicossociais:_____________________________________________________
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Funcionamento global:_______________________________________________________
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:_________________________________
EVERALDO DE CARVALHO 2022
CPF: 278.395.308-00
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Uso de drogas?_____________________________________________________________
Tentativa de suicídio?_______________________________________________________
Focos de intervenção psicoterápica:_____________________________________________
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Relacionamentos Importantes
Conjuje:__________________________________________________________________
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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:_________________________________________________________
EVERALDO DE CARVALHO 2022
CPF: 278.395.308-00
Psicó logo CRP 06/90100
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Infância
Adolescência
EVERALDO DE CARVALHO 2022
CPF: 278.395.308-00
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Vida Adulta
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Observações:______________________________________________________________________
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Atendimentos Prestados
Profissional:_______________________________________________________________
Encaminhamentos Feitos:____________________________________________________
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):_____________
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