FICHA DE TRIAGEM

Nome:________________________________________________________________________

Data de nascimento:____________________________________________________________

Endereço:_____________________________________________________________________
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Filiação:______________________________________________________________________
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Quantas pessoas moram na casa?__________________________________________________

Quantas pessoas trabalham ?_____________________________________________________

Renda média:__________________________________________________________________

Queixa:_______________________________________________________________________
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Melhor dia e horário para o atendimento:___________________________________________

Valor das sessões:______________________________________________________________

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Psicóloga responsável