Ficha de Acolhimento/Anamnese/ Triagem Nº prontuário

Data da triagem _____/_____/_________

Nome completo do Usuário: Idade:

Estagiário Responsável:
Supervisor: CRP:
Abordagem teórica:

Queixa e Demanda
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Aspectos Gerais do Usuário (aparência, linguagem, cognição, pensamento, consciência,
afeto, humor, juízo, etc.)
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Aspectos Psicossociais do Usuário:

● Vida laboral/ trabalho/ ocupação
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● Rede de apoio
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● Lazer/diversão/tempo livre
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● Afetividade e sexualidade
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● Aspectos econômicos/financeiros
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● Religiosidade/ religião/espiritualidade/se houver.
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Histórico da sintomatologia pregressa e atual:

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História de vida:
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Outros aspectos:
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Impressões e Hipóteses:
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Foi realizado algum tipo de intervenção ou orientação? Qual?

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Encaminhamento/indicação (qual tipo de acompanhamento é mais adequado nessa
situação?)
Interno (na Clínica de Psicologia) ( ). Qual tipo? ____________________________
Externo ( ) qual local/ serviço? ________________________________________

É situação de risco? Sim ( ) Não ( ). Se sim, porquê?

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Obs: favor, certificar-se das regras de admissão para atendimento - CEFAB.

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Assinatura Estagiário

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Assinatura e CRP do supervisor