TRIAGEM

ROTEIRO DE ENTREVISTA INICIAL

Nº do prontuário: _____________ DATA: ____/____/______

1 – IDENTIFICAÇÃO:

1.1. Nome:_____________________________________________________________
1.2. Data de nascimento: ____/____/______ Idade:________________________
Natural de:__________________________________________________________
Estado Civil:_____________________ Sexo: ( ) F ( ) M RG.:_______________
1.3. Nível de Instrução: ( ) Ensino Fundamental __________________
( ) Ensino Médio _______________________
( ) Ensino Superior _____________________
1.4. Escola:_______________________________ Período:__________________
1.5. Profissão ou ocupação:_____________________Salário:________________
1.6. Religião:_______________________________________________________
1.7. Rua/Av.:_______________________________________________n°______
Bairro: _______________________ Cidade: __________________ UF:_____
CEP: ________________________ Fone: ____________________________

2 . COMPOSIÇÃO FAMILIAR
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3. MOTIVOS PARA A PROCURA DE ATENDIMENTO PSICOLÓGICO NO C.E.P.P.
(SEGUNDO O INFORMANTE):

3.1. QUEIXA INICIAL: (PRINCIPAL)

(obs.: incluir breve histórico / use o verso se necessário)
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3.2. OUTRAS QUEIXAS:

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4 – INFORMAÇÕES GERAIS:

4.1. Tratamentos anteriormente realizados:

Local: _________________________
Período: ___/__/____ a ___/___/____
Motivo(s): _______________________________________________________________
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4.2. Encaminhado à Psicoterapia/C.E.P.P. por:
Local: __________________________________________________________________
Motivo do encaminhamento: ________________________________________________
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Urgência para atendimento (segundo o informante): muita( ) média( ) pouco( )

4.3. Disponibilidade de horário para os atendimentos (especificar dia e horário):

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4.4. No caso de crianças (Nome do informante):

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Grau de parentesco com a criança: ___________________________________________

5 – OBSERVAÇÕES FINAIS:

5.1. Indicado atendimento na (s) área (s): _________________________________

5.2. Outras:

Data ____/ ____/____

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Assinatura do estagiário Assinatura do supervisor