ENTREVISTA DE ACOLHIMENTO

(Triagem)

Escola: ____________________________________________________________________
Aluno (a): ___________________________________________________________________
Professor (a): ____________________________________ Ano: ______________________
Idade:____________ Repetente? _____________ Que ano repetiu? _______________
Pai: _______________________________________________________________________
Mãe: _______________________________________________________________________
Endereço:___________________________________________________________________
Contato: __________________________________________________________________-
Encaminhado por:_____________________________________________________________

Queixa:_____________________________________________________________________
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Usa medicação, qual ?_________________________________________________________
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Obs: Estes encontros foram realizado no dia-------------------- na Escola--------------------------------------------------------