ENTREVISTA FAMILIAR:

Nome do Interno: ___________________________________________________________

Nome Familiar Entrevistado:

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Quando a família descobriu:

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Tipo de droga: __________________________________________________________________________

Tempo de uso: _________________________________________________________________________  

 Modo de uso: ___________________________________________________________________________

Com quem usa ou usava? __________________________________________________________________

Qual o comportamento quando usava droga? __________________________________________________

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Como sustentava a dependência:  (     ) Trabalhando                (       ) Com a ajuda da família

                                                    (    ) Trocando objetos        (       ) Outros

 Tem dívidas: (     ) Sim   (     ) Não

 INTERNAÇÕES ANTERIORES:

Onde:__________________________________________________________________________________
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Quanto tempo: __________________________________________________________________________

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Rua. Wilson Mario Dos Santos , Nº 1, Residencial Flamboyant, Piratininga, Estado de São Paulo,

Escritório (14) 3265-3494 Clínica vivo(14) 99739-9278

Cumpriu o programa: _____________________________________________________________________
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Houve Recaída: _________________________________________________________________________

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Houve abstinência: _______________________________________________________________________

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Tempo: ________________________________________________________________________________
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SITUAÇÃO PROFISSIONAL DO FAMILIAR:

Está trabalhando: (    ) Sim   (     ) Não          

Profissão: ______________________________________________________________________________

SITUAÇÃO PROFISSIONAL DO INTERNO:

Estava trabalhando antes da Internação? ( ) SIM ( )NÃO Onde? _________________________

Autônomo: ( ) SIM ( ) NÃO Se não qual empresa trabalhava? _______________________________

O empregador sabe da dependência química/ou alcoólica ( ) SIM ( ) NÃO

O empregador pretende ajudar:                                         ( ) SIM (  ) NÃO

ESCOLARIDADE FAMILIAR:

Estuda: ( ) SIM    ( ) NÃO   Curso: __________________________________________________

Nível de escolaridade: ( )Fundamental           ( ) Médio            ( ) Superior

Cursos Extras: __________________________________________________________________________

Desenvolvimento Escolar: _________________________________________________________________

FAMÍLIA ASCENDENTE:

Os pais ou o casal são casados legalmente? ____________________________________________________

_______________________________________________________________________________________
Situação atual do casamento: ______________________________________________________________
_______________________________________________________________________________________

Os pais ou casal vivem juntos: ______________________________________________________________

_______________________________________________________________________________________

Rua. Wilson Mario Dos Santos , Nº 1, Residencial Flamboyant, Piratininga, Estado de São Paulo,

Escritório (14) 3265-3494 Clínica vivo(14) 99739-9278

Relacionamento com os pais: _______________________________________________________________
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Relacionamento com os irmãos: _____________________________________________________________

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Relacionamento com os filhos: _____________________________________________________________

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CASOS RELACIONADOS COM A FAMÍLIA ASCENDENTE

Coloque S para SIM e N para NÃO

( ) Dependência Química ( ) Doenças Pulmonares ( ) Doença Mental ( ) AIDS

(   ) Diabete ( ) Epilepsia ( ) Hipertenção ( ) Desmaios ( ) Cardiopatia ( ) Outras Doenças

Quem tomou iniciativa de internação? ________________________________________________________

É voluntária? ( ) SIM ( ) NÃO  

Por que? _______________________________________________________________________________

_______________________________________________________________________________________

A família pretende conhecer o local oferecido pela instituição?  ( ) SIM ( ) NÃO

_______________________________________________________________________________________
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Expectativa do Familiar: __________________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Dificuldade do Familiar: __________________________________________________________________

_______________________________________________________________________________________
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Rua. Wilson Mario Dos Santos , Nº 1, Residencial Flamboyant, Piratininga, Estado de São Paulo,

Escritório (14) 3265-3494 Clínica vivo(14) 99739-9278

Parecer Técnico do Assistente Social:
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Rua. Wilson Mario Dos Santos , Nº 1, Residencial Flamboyant, Piratininga, Estado de São Paulo,

Escritório (14) 3265-3494 Clínica vivo(14) 99739-9278