NÚCLEO DE PSICOLOGIA APLICADA

ROTEIRO DE ENTREVISTA PARA ADULTOS

Nome: ________________________________________________________________________
Idade: _________ Data de Nascimento: ___________________ Estado Civil:________________
Profissão: _______________________ Escolaridade: __________________________________
Endereço: _____________________________________________________________________
CEP: ______________________ Cidade/Estado: ______________________________________

Queixa Atual: ___________________________________________________________________

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História Médica/ Psiquiátrica:
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Histórico de doença mental na família:

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História Social: __________________________________________________________________

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Núcleo de Psicologia Aplicada – NPA
Rua Dos Carijós 1034, em frente ao número 1079 – Bairro Centro, CEP: 30.120-060 – Belo Horizonte/MG Telefone: 4009 0950
 NÚCLEO DE PSICOLOGIA APLICADA

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História Familiar (incluir genograma): _________________________________________________
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Genograma:

Descrição do relacionamento familiar:

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Histórico Escolar: ______________________________________________________________

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Histórico Ocupacional: ____________________________________________________________

Núcleo de Psicologia Aplicada – NPA

Rua Dos Carijós 1034, em frente ao número 1079 – Bairro Centro, CEP: 30.120-060 – Belo Horizonte/MG Telefone: 4009 0950
 NÚCLEO DE PSICOLOGIA APLICADA

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Descreva a rotina de um dia habitual da sua vida, do despertar ao recolher.

Manhã: ________________________________________________________________________
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Tarde: __________________________________________________________________________
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Noite: __________________________________________________________________________
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AVALIAÇÃO DO CASO

Núcleo de Psicologia Aplicada – NPA

Rua Dos Carijós 1034, em frente ao número 1079 – Bairro Centro, CEP: 30.120-060 – Belo Horizonte/MG Telefone: 4009 0950
 NÚCLEO DE PSICOLOGIA APLICADA

Impressões do entrevistador
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Hipótese(s) Diagnóstica
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Plano de Intervenção/ Encaminhamento

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Assinatura do(a) Aluno(a) Responsável pela Entrevista

Data da entrevista:___/____/_________

Supervisor Responsável: ___________________________________________________________

CRP:

Núcleo de Psicologia Aplicada – NPA

Rua Dos Carijós 1034, em frente ao número 1079 – Bairro Centro, CEP: 30.120-060 – Belo Horizonte/MG Telefone: 4009 0950