ISTORICUL SOCIAL

I. Date privind identificarea beneficiarului

Numele i prenumele
Locul i data naterii

(zz)/(ll)/(aaaa)
Loc.

Jud.

CNP
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Statut juridic/starea civil
Domiciliul

II. Date privind familia beneficiarului

Date de identificare ale membrilor familiei
Numele i prenumele

Vrsta

Ocupaia

Date relevante privind familia

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Domiciliul

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III. Date privind evoluia beneficiarului
Informaii despre natere i dezvoltare
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Informaii medicale
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Activitatea colar

Statut socio-profesional

IV. Situaia material / financiar

Locuin/proprieti

Surse de venit

Relaia cu sistemul de protecie/asisten social

Anul/P Anul/Perioada

Msur Msura de protecie Institu

Instituia

Msur Msura permanent

V. Probleme identificate
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Asistent Social ______________________________________

Instituia

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Data

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