FICHA DE IDENTIFICAÇÃO E DAS CONDIÇÕES DE SAÚDE FÍSICA E PSICOLÓGICA

1. Dados de identificação:

Nome:___________________________________________________________________________________________________________
Sexo: ☐ Masc / ☐ Fem. Data de nascimento: _______/________/________ Idade: ____________
Endereço: (Rua/Av.)__________________________________________________________________________Nº______________
Email: ___________________________________________________________________________________________________________
Telefones: Celular (____) ____________________________
Contato de Emergência (____) _______________________________
Filhos: ☐ Nã o / ☐ Sim: quantos? _______________

2. Dados acadêmicos:
☐ Sem escolaridade
☐ Alfabetizado
☐ Ensino Fundamental
☐ Ensino médio
☐ Técnico/Superior

3. Dados profissionais

Profissã o: ___________________________________________________________________
Ocupaçã o: ___________________________________________________________________

4. Experiência psicoterapêutica:

☐ Faz psicoterapia pela primeira vez / ☐ Já fez terapia anteriormente

OBS. _______________________________________________________________________________________________________________

5. Condição de saúde física atual:

Atualmente sofre de algum problema de saúde?

informar: _________________________________________________________________________________________________________

Sobre uso de medicamentos:

☐ Nã o faz uso de nenhum medicamento atualmente

☐ Utiliza medicamento(s): informar qual(ais):
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Sobre uso de substâncias psicoativas:

Tabaco: ☐nã o ☐sim / Á lcool: ☐nã o ☐sim, Eventual - ☐sim, Constante / Drogas: ☐nã o ☐sim.
OBS:_______________________________________________________________________________________________________________

6- Variações no humor:
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7- Interação com a família, amigos e pessoas do trabalho:

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8- Nível geral de funcionamento em casa, no trabalho e em outros lugares.

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9- Como passa o tempo livre

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10- Atividades que proporciona uma sensação de prazer, realização e/ou conexão:

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11- Atividade de autocuidado:

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12- Atividades que está evitando:

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13- Definindo objetivos: