FICHA DE REGISTRO

Data: ____/____/_____
Nome: _____________________________________________________________________
Mãe: _______________________________________________________________________
Pai: ________________________________________________________________________
Data de nascimento.: ____/____/______ Idade: ____________
Fone Res.: __________________Celular: __________________ Com: __________________
Escola: _____________________________________________________________________
Escolaridade: ________________________________________________________________
Turno: _______________ Reforço escolar: ( ) sim ( ) não Obs: ________________________
Atividades extras: ______________________________________________________________
Medicação: ( ) sim ( ) não Qual? _______________________________________________
Faz acompanhamento com algum especialista? ( ) sim ( )não Qual? _____________________
Se sim, há quanto tempo? ________________________________________________________
Tipo de Atendimento: ( ) Avaliação ( ) Intervenção ( ) Outros_____________________
Horário: ______________________________________________________________________
Valor da sessão R$ _____________________________________________________________
Forma de pagamento: ( ) dinheiro ( )débito ( ) crédito Obs:____________________________
Motivo do Encaminhamento/Queixa:
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