Formulário de Acolhimento Psicológico

Anamnese Adulto
Data:_______________
Nome:________________________
______________________________
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Idade:_____________
Sexo:_______________
CPF:__________________________
__
Identidade:_____________________
__________
Endereço:______________________
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____________________
 Formulário de Acolhimento Psicológico

______________________________
______________________________
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Telefones para
Contato:_______________________
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_
Bairro:________________________
____
Cidade:________________________
________
Religião:______________________
_____
Escolaridade:___________________
________
 Formulário de Acolhimento Psicológico

Filhos (nome, idade e

sexo)_________________________
__________________________
______________________________
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______________________________
______________________________
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Profissão:______________________
______________________________
_____________
Est.Civil:___________________
Cônjuge (nome, idade, profissão,
escolaridade):___________________
_______________
 Formulário de Acolhimento Psicológico

______________________________
______________________________
_____________
Queixa
principal:______________________
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_______
______________________________
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______________________________
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Fez terapia anteriormente? (citar qual
e
 Formulário de Acolhimento Psicológico

quando)_______________________
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______________________________
______________________________
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Expectativas e objetivos do
paciente:_______________________
____________________
______________________________
______________________________
____________________
______________________________
______________________________
______
Sintomas
apresentados:___________________
 Formulário de Acolhimento Psicológico

______________________________
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____________________
______________________________
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Doenças
físicas:________________________
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_____________
 Formulário de Acolhimento Psicológico

Estressores
psicossociais:___________________
______________________________
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______________________________
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Funcionamento
global:________________________
______________________________
_
Anamnese Adulto Data: _______________

Nome: _______________________________________________________________________________
Idade: _____________ Sexo: _____________________ Estado Civil: ________________________
CPF: _______________________________ Identidade: __________________________________
Endereço: _____________________________________________________________________________
Bairro: ________________________________________ Cidade: _______________________________
 Formulário de Acolhimento Psicológico
Religião: ___________________________ Escolaridade: ______________________________________
Telefones para Contato: __________________________________________________________________
______________________________________________________________________________________
Filhos (nome, idade e sexo): _______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Profissão: _____________________________________________________________________________
Cônjuge (nome, idade, profissão, escolaridade): _______________________________________________
______________________________________________________________________________________
Queixa principal: ________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Fez terapia anteriormente? (Citar qual e quando): ______________________________________________
______________________________________________________________________________________
Expectativas e objetivos do paciente: ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Sintomas apresentados: ___________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Doenças físicas: _________________________________________________________________________

_______________________________________________________________________________________
Estressores psicossociais: __________________________________________________________________
_______________________________________________________________________________________
Funcionamento global: ____________________________________________________________________

Conceituação Psicológica do
Caso:_________________________
____________________
 Formulário de Acolhimento Psicológico

______________________________
______________________________
____________________
______________________________
______________________________
______
Transtornos psiquiátricos
anteriores:_____________________
_______________________
Transtornos psiquiátricos
familiares:_____________________
_______________________
Doenças Importantes que
teve:__________________________
______________________
 Formulário de Acolhimento Psicológico

Medicação que está

tomando:______________________
___________________________
Medicação alternativa (chás,
compostos,
etc.)__________________________
___________
Aplicação de Testes? Se sim, qual e
resultado:______________________
______________
______________________________
______________________________
____________________
______________________________
______________________________
____________________
 Formulário de Acolhimento Psicológico

______________________________
_____________________________
Histórico da Queixa
Quando se
iniciou:________________________
______________________________
____
______________________________
______________________________
____________________
______________________________
______________________________
______
Eventos traumáticos de
vida:__________________________
________________________
 Formulário de Acolhimento Psicológico

______________________________
______________________________
____________________
______________________________
______________________________
______
Eventos/fatores que precipitam ou
agravam
crises:_________________________
________
______________________________
______________________________
_____________
Uso de drogas?
______________________________
 Formulário de Acolhimento Psicológico

______________________________
_
Tentativa de suicídio?
______________________________
_________________________
Focos de intervenção
psicoterápica:___________________
__________________________
Conceituação Psicológica do Caso: __________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Transtornos psiquiátricos anteriores: _________________________________________________________
Transtornos psiquiátricos familiares: _________________________________________________________
Doenças Importantes que teve: _____________________________________________________________
Medicação que está tomando: ______________________________________________________________
Medicação alternativa (chás, compostos, etc.): _________________________________________________
Aplicação de Testes? Se sim, qual o resultado: _________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Histórico da Queixa
Quando se iniciou: ________________________________________________________________________
________________________________________________________________________________________
 Formulário de Acolhimento Psicológico
________________________________________________________________________________________
Eventos traumáticos de vida: ________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Eventos/fatores que precipitam ou agravam crises: _______________________________________________
________________________________________________________________________________________
Uso de drogas? Quais? _____________________________________________________________________
________________________________________________________________________________________
Tentativa de suicídio? ______________________________________________________________________

Focos de intervenção psicoterápica: ___________________________________________________________

Conceituação Psicológica do
Caso:_________________________
____________________
______________________________
______________________________
____________________
______________________________
______________________________
______
 Formulário de Acolhimento Psicológico

Transtornos psiquiátricos
anteriores:_____________________
_______________________
Transtornos psiquiátricos
familiares:_____________________
_______________________
Doenças Importantes que
teve:__________________________
______________________
Medicação que está
tomando:______________________
___________________________
Medicação alternativa (chás,
compostos,
etc.)__________________________
___________
 Formulário de Acolhimento Psicológico

Aplicação de Testes? Se sim, qual e

resultado:______________________
______________
______________________________
______________________________
____________________
______________________________
______________________________
____________________
______________________________
_____________________________
Histórico da Queixa
Quando se
iniciou:________________________
______________________________
____
 Formulário de Acolhimento Psicológico

______________________________
______________________________
____________________
______________________________
______________________________
______
Eventos traumáticos de
vida:__________________________
________________________
______________________________
______________________________
____________________
______________________________
______________________________
______
 Formulário de Acolhimento Psicológico

Eventos/fatores que precipitam ou

agravam
crises:_________________________
________
______________________________
______________________________
_____________
Uso de drogas?
______________________________
______________________________
_
Tentativa de suicídio?
______________________________
_________________________
 Formulário de Acolhimento Psicológico

Focos de intervenção
psicoterápica:___________________
__________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Relacionamentos Importantes
Cônjuge: ________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Mãe: ___________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Pai: ____________________________________________________________________________________
________________________________________________________________________________________
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Irmãos: _________________________________________________________________________________
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Filhos: __________________________________________________________________________________
________________________________________________________________________________________
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Outros importantes: _______________________________________________________________________
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 Formulário de Acolhimento Psicológico
Observações sobre dinâmica familiar atual: _____________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Infância
Gravidez (planejada ou não), parto, intercorrências obstétricas: _____________________________________
________________________________________________________________________________________
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Amamentação: ___________________________________________________________________________
________________________________________________________________________________________
Treinamento de Higiene: ___________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Estressores na infância, crises: _______________________________________________________________
________________________________________________________________________________________
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Outros transtornos infantis (sono, alimentação, psicomotor, gagueira, tiques, sonambulismo, aprendizagem):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Outros comentários: ________________________________________________________________________
_________________________________________________________________________________________
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Adolescência
Experiências afetivas marcantes: ______________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Experiências sexuais marcantes: _______________________________________________________________
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 Formulário de Acolhimento Psicológico
_________________________________________________________________________________________
Independência/ primeiros empregos: ___________________________________________________________

Formulário de
Acolhimento
Psicológico 2021
______________________________
______________________________
____________________
______________________________
______________________________
______
Círculo de
amizades:______________________
______________________________
____
 Formulário de Acolhimento Psicológico

______________________________
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____________________
______________________________
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Vida Adulta
Relacionamento com
parceiro:_______________________
__________________________
______________________________
______________________________
____________________
______________________________
______________________________
______
 Formulário de Acolhimento Psicológico

Vida Sexual
Atual:_________________________
______________________________
___
______________________________
______________________________
____________________
______________________________
______________________________
______
Situação
Financeira:_____________________
______________________________
______
 Formulário de Acolhimento Psicológico

______________________________
______________________________
_____________
Abortos
espontâneos/provocados:__________
______________________________
______
Apoio Social
disponível:_____________________
______________________________
__
______________________________
______________________________
_____________
Outros transtornos atuais (sono,
alimentação,
 Formulário de Acolhimento Psicológico

tiques,etc.):____________________
_______
______________________________
______________________________
_____________
Principais lazeres, vida
social:_________________________
________________________
______________________________
______________________________
____________________
______________________________
______________________________
______
Observação e Linguagem Não verbal
do Paciente
 Formulário de Acolhimento Psicológico

Observações:___________________
______________________________
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_________________________________________________________________________________________
_________________________________________________________________________________________

Círculo de amizades: ________________________________________________________________________

 Formulário de Acolhimento Psicológico
_________________________________________________________________________________________
_________________________________________________________________________________________

Vida Adulta
Relacionamento com parceiro: ________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Vida Sexual Atual: _______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Situação Financeira: ______________________________________________________________________
_______________________________________________________________________________________
Abortos espontâneos/provocados: ___________________________________________________________
Apoio Social disponível: ___________________________________________________________________
_______________________________________________________________________________________
Outros transtornos atuais (sono, alimentação, tiques, etc.): ________________________________________
_______________________________________________________________________________________
Principais lazeres, vida social: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Observação e Linguagem não verbal do Paciente

Observações: ____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Atendimentos Prestados
 Formulário de Acolhimento Psicológico

Profissional: ____________________________________________________________________________
Encaminhamentos Feitos: __________________________________________________________________
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.): __________________________
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Georgea Marcela Santos Cardoso
Psicoterapeuta