INTERVIU CUNOASTERE

NUMELE SI PRENUMELE ____________________________________ Vrsta ___________________

Subliniai ceea ce se potrivete copilriei / adolescenei dvs. :
Copilrie fericit
Copilrie nefericit
Probleme legale
Probleme educaionale
Probleme comportamentale
Abuz de alcool

probleme medicale
probleme colare
probleme familiale
convingeri religioase puternice
abuz de drog
altele_____________________________________

Care este nlimea dvs.?__________Care este greutatea dvs.?_________

Ai fost vreodata spitalizat pentru probleme psihiatrice?
Da(detalii)____________________________________________________________________________________
_____________________________________________________________________________________________
Nu

Avei medic de familie ?

Da (nume, nr. de telefon)_________________________________________________________________________
Nu

Ai avut tentative suicidare ?

Da(detalii context, consecine)_____________________________________________________________________
______________________________________________________________________________________________
Nu
Sufer cineva din familia dvs. de : alcoolism___________________________________________________________
depresie__________________________________________________________________
epilepsie_________________________________________________________________
_
orice altceva care poate fi considerat ,,tulburare mental ? ______________________________________________
_______________________________________________________________________________________________
A avut / comis vreo rud tentativa de suicid ?__________________________________________________________
A avut / are vreo rud probleme cu legea?____________________________________________________________

Analiza, pe modaliti, a problemelor dvs. actuale

Seciunea urmtoare este conceput pentru a v ajuta s v descriei problemele curente n detaliu i pentru a le
identifica pe cele care ar putea trece neobservate. Aceasta ne va permite s concepem un program de asistare cuprinztor i
adaptat nevoilor dvs. specifice.

1. Comportament
Subliniai fiecare din comportamentele urmtoare care v caracterizeaz :
Supraalimentaie
Consum de droguri
Vom
Comportament ciudat
Consum prea mare de butur
Munc prea mult/ grea
Amnare
Reacii impulsive
Pierderea controlului
Asumare a prea multor riscuri
Tentative suicidare
Compromisuri
Fumat
Izbucniri de furie (ieit din srite)

retragere
ticuri nervoase
dificulti de concentrare
tulburri de somn
evitare fobic
incapacitate de a desfura un anumit
tip de munc (mutri frecvente)
insomnie
lene
probleme de alimentaie
comportament agresiv
plns

Exist comportamente, aciuni sau obiceiuri pe care ai dori s le schimbai ?____________

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Care sunt talentele/ aptitudinile/ abilitile cu care v mndrii ? _______________________________

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Ce ai vrea s facei mai mult?____________________________________________________________
Ce ai vrea s facei mai puin ?___________________________________________________________
Ce ai vrea s ncepei s facei ?__________________________________________________________
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Ce ai vrea s ncetai s mai facei ? ______________________________________________________
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Cum v petrecei timpul liber ?____________________________________________________________
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n compania cui ?(detalii anturaj) __________________________________________________________
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V meninei ocupat n mod compulsiv fcnd un ir nesfrit de activiti nesemnificative ?
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2. Sentimente
Subliniai fiecare din sentimentele urmtoare care vi se potrivesc (pe care le resimii) adesea :
furios
plictisit
suprat
deprimat
anxios
temtor
panicat

energic
invidios
vinovat
fericit
conflictual
plin de regrete
lipsit de speran

plin de speran
relaxat
gelos
nefericit
trist
fr odihn
singur

mulumit
stimulat
optimist
tensionat
altele

Listai principalele frici/ temeri ale dvs. :

1.____________________________________________________________________________________
2.____________________________________________________________________________________
3.____________________________________________________________________________________
4.____________________________________________________________________________________
5.____________________________________________________________________________________
Care sunt sentimentele pe care le ncercai cel mai des ?________________________________________________
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Ce sentimente / emoii ai vrea s trii mai puin des ?_________________________________________________
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Enumerai cteva din sentimentele/ emoiile pozitive pe care le-ai trit de curnd ?__________________________
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Cnd suntei cel mai adesea pe cale s v pierdei controlul asupra sentimentelor/ emoiilor dvs. ?
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Descriei o situaie semnificativ pentru acest lucru ___________________________________________________
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Descriei situaiile care v fac s v simii calm, relaxat _______________________________________________
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V rugm s completai :
Dac v-a spune ce simt acum ______________________________________________________________________
Unul din lucrurile de care m simt mndru este ________________________________________________________
Unul din lucrurile de care m simt vinovat este ________________________________________________________
Sunt
cel
mai
fericit
cnd
___________________________________________________________________________
Unul din lucrurile care m supr cel mai tare este _____________________________________________________
Dac nu mi-ar fi team s fiu eu nsumi, a putea s ____________________________________________________
Dac m supr pe tine ____________________________________________________________________________

Ce fel de lucruri recreative sau hobby-uri v fac plcere, v relaxeaz ? _________________________________

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Avei dificulti s v relaxai/ odihnii/ distrai n weekend-uri i vacane?_________________________________
Dac da, v rugm s explicai ___________________________________________________________________
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3. Senzaii fizice
Subliniai senzaiile pe care le resimii adesea :
Dureri de cap
Ameeal
Palpitaii
Spasme musculare
Tensiune
Tulburri sexuale
Incapacitate de relaxare
Tulburri intestinale
Furnicturi
iuituri n urechi

deranj stomacal
probleme de piele
ticuri
gura uscat
oboseal
mncrimi sau arsuri de piele
contracii musculare
dureri de piept
dureri de spate
bti rapide de inim
tremurturi
neplcerea de a fi atins
momente de lein/slbiciune
zgomote auzite
transpiraie excesiv
ochi apoi
tulburri de vedere
probleme de auz
amoreal

4. Imagini
Subliniai fiecare din elementele care v caracterizeaz :
Imagini sexuale plcute
Imagini de neajutorare
Imagini agresive

imagini sexuale neplcute

imagini de singurtate
imagini de seducie

imagini de a fi iubit

Verificai care din urmtoarele vi se potrivesc :

M vd pe mine nsumi (m imaginez) ca:
Fiind lovit
Neputnd s fac fa
Avnd succes
Pierzndu-mi controlul
Fiind urmrit

fiind brfit
lovind pe alii
fiind responsabil
eund
fiind prins n curs

fiind ridiculizat
fcnd promisiuni
altele________________________________________
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_____________________________________________

Ce imagine v vine n minte cel mai des ? _________________________________________________________

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Descriei o imagine, un tablou mental sau o fantezie foarte plcut ____________________________________
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Descriei o imagine, un tablou mental sau o fantezie foarte neplcut __________________________________
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Descriei imaginea dvs. despre un loc complet sigur _________________________________________________

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5. Gnduri
Subliniai fiecare din urmtoarele gnduri care vi se potrivesc:
- Sunt lipsit de valoare, un nimeni, inutil i/ sau nedemn de a fi iubit
- Sunt neatrgtor, incompetent, stupid i/ sau indezirabil
- Sunt ru, nebun, degenerat i/ sau deviant
- Viaa este goal, un pustiu, nu este nimic spre care s caui s te ndrepi (n viitor)
- Fac prea multe greeli, nu fac nimic corect, bine

Subliniai fiecare din urmtoarele cuvinte pe care le-ai putea utiliza pentru a v descrie:
Inteligent
ncreztor
Meritoriu (valoros)
Ambiios
Sensibil
Loial
De ncredere
Plin de regrete
Lipsit de valoare
Un nimeni
Inutil
Ru
Nebun

degenerat
moral
atent
un deviant
neatrgtor
nedemn de a fi iubit
inadecvat
confuz
urt
prost
stupid
naiv
onest

incompetent
cu gnduri oribile
conflictual
cu dificulti de concentrare
cu probleme de memorie
atrgtor
nu pot lua decizii
cu idei suicidare
perseverent
ncpnat
bun sim al umorului
muncitor

Care considerai c este cel mai iraional gnd (idei pe care le avei)? ________________________________________
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Suntei deranjat de gnduri care revin mereu ? _______________________________________________________

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Pentru fiecare din itemii urmtori, v rugm ncercuii numrul care reflect cel mai fidel opiniile dvs. :
1.dezacord puternic
2.dezacord
3. neutru
4. acord
5. acord puternic
a) Ar trebui s nu fac greeli
b) Trebuie s fiu bun n tot ce fac
c) Cnd nu tiu, ar trebui s pretind c tiu
d) Ar trebui s nu dezvlui informaii personale
e) Sunt o victim a circumstanelor
f) Viaa mea este controlat de fore exterioare
g) Ali oameni sunt mai fericii dect mine
h) Este foarte important s-i mulumeti pe ceilali
i) Joac singur; nu-i asuma nici un fel de riscuri
j) Nu merit s fiu fericit
k) Dac mi ignor problemele, ele vor disprea
l) Este responsabilitatea mea s-i fac pe ceilali oameni fericii
m) Trebuie s tind/ s m strduiesc spre perfeciune
n) La baz sunt dou moduri de a face lucrurile : modul bun
corect i modul prost, greit

a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
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n)

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V rugm s completai urmtoarele :

Sunt o persoan care _____________________________________________________________________________
Toat viaa mea _________________________________________________________________________________
nc
de
cnd
eram
copil
___________________________________________________________________________
Este greu pentru mine s admit _____________________________________________________________________
Unul din lucrurile pe care nu le pot ierta este __________________________________________________________
Cnd i faci probleme ____________________________________________________________________________

Lucrul ru cnd creti mare este ____________________________________________________________________

Unul din modurile n care a putea s m ajut , dar nu o fac este __________________________________________

_______________________________________________________________________________
6. Relaiile interpersonale
A. Familia de origine
Dac nu ai fost crescut de prini, cine v-a crescut i ntre ce ani ?___________________________________
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Dai o descriere a personalitii tatlui (sau a substitutului tatlui) i a atitudinii lui (prezente i trecute) fa
de dvs. ___________________________________________________________________________________
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Dai o descriere a personalitii mamei (sau a substitutei mamei) i a atitudinii ei (prezente i trecute) fa de
dvs.
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n ce moduri ai fost disciplinat ( pedepsit) de prini cnd erai copil ?________________________________
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Relatai o impresie asupra atmosferei casei dvs. (casa n care ai crescut). Menionai starea de compatibilitate
dintre prini i dintre prini i copii. __________________________________________________________
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Puteai s avei ncredere/ s v confesai prinilor dvs. ? __________________________________________
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V nelegeau prinii dvs. ? __________________________________________________________________
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n fond, v-ai simit iubit i respectat de prini ? __________________________________________________
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Dac avei un printe vitreg, precizai vrsta la care printele s-a recstorit___________________________
S-a amestecat vreodat cineva (prini, rude, prieteni) n mariajul sau munca dvs., etc.? __________________
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Care sunt cei mai apropiai oameni din viaa dvs.? ________________________________________________
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B. Prietenii
1.
V
facei
prietenii
cu
uurin______________________________________________________________
2.
i
pstrai ?
____________________________________________________________________________
3.
Ai
fost
vreodat
terorizat
sau
ironizat
dur ?
__________________________________________________
4.
Descriei o relaie care v ofer:
Bucurie _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Suprare ______________________________________________________________________________

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Notai msura n care v simii n general confortabil i relaxat n situaiile sociale

5.

(ncercuii) :
Foarte relaxat

relativ confortabil

relativ inconfortabil

foarte anxios

6. n general, v exprimai sentimentele, opiniile sau dorinele ntr-un mod deschis i adecvat ?
____________
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Descriei indivizii fa de care (sau ntrebrile n care) avei dificulti s fii asertivi.__________________________
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_
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_
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_

7. Avei unul sau mai muli prieteni cu care s v simii confortabil, s v mprtii cele mai intime gnduri
sau sentimente ? ___________________________________________________________________________
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C. Mariaj
a. De ct timp v cunoteai soia/ soul nainte de a v logodi ?
_________________________________________________________________________________________
b. Ct timp ai fost cstorit ? _______________________________________________________________
c. De ct timp suntei cstorit ? ____________________________________________________________
d. Care este vrsta soiei/ soului dvs. ? _______________________________________________________
e. Care este ocupaia soiei/ soului dvs. ?_____________________________________________________
f. Descriei personalitatea soiei/ soului dvs. __________________________________________________
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g. n ce arii suntei compatibili ? ____________________________________________________________
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h. n ce arii suntei incompatibili ? ___________________________________________________________
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i. Cum v nelegei cu rudele dvs. prin alian (socrii, cumnai etc)? ________________________________
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j. Ci copii avei ? ____________Numele lor : _________________________________________________
_____________________________Vrsta ______________________________________________________
k. Prezint vreunul dintre ei probleme speciale ? ________________________________________________
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D. Relaii sexuale
Descriei atitudinea prinilor dvs. fa de sex. Se discuta despre sex acas?
______________________________________________________________________________________
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Cnd i unde ai obinut primele informaii despre sex?
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Cnd ai devenit prima dat contient de propriile impulsuri sexuale ?

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Ai trit vreodat sentimente de anxietate sau vinovie provocate de sex sau masturbare ? Dac da, v
rugm s explicai_______________________________________________________________________
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Detalii relevante privind prime experien sexual sau cele ulterioare______________________________
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Viaa dvs. sexual prezent este satisfctoare? Dac nu, v rugm explicai
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Oferii informaii despre orice reacie sau relaie homosexual
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V rugm notai orice problem/ preocupare sexual nediscutat mai sus
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E. Alte relaii
a.
Sunt probleme n relaiile cu oamenii la serviciu? Dac da, v rugm descriei
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b.
V rugm completai urmtoarele :
i.
unul
din
modurile
n
care
oamenii
m
rnesc
este______________________________________________
______________________________________________________________________________________
ii.
a
putea
s
ochez
prin___________________________________________________________________
iii.
o
mam
ar
trebui
_______________________________________________________________________
iv.
un
tat
ar
trebui
________________________________________________________________________
v.
un
prieten
adevrat
ar
trebui
______________________________________________________________
c.
Dai o scurt descriere a dvs. aa cum ai fi descris de :
a) soia/ soul dvs._______________________________________________________________________
b) cel mai bun prieten ____________________________________________________________________
c) cineva care v agreaz _________________________________________________________________
d) cineva care nu v agreaz ______________________________________________________________
d.
Suntei n mod obinuit afectat de faptul de a fi respins n trecut sau de pierderea unei relaii de
prietenie/ colegialitate ? Dac da, v rugm explicai___________________________________________
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e.
Suntei n mod obinuit afectat de faptul de a fi respins n trecut sau de pierderea unei relaii
de
dragoste?
Dac
da,
v
rugm
explicai_______________________________________________________
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7. Factorii biologici
Verificai (ncercuii) care din urmtoarele v caracterizeaz (vi se potrivesc):
Avei preocupri curente legate de sntatea dvs. fizic ? V rugm explicai
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V rugm enumerai medicamentele pe care le luai n mod curent sau pe care le-ai luat n ultimele 6 luni
(inclusiv aspirin, pilule anticoncepionale sau medicamente prescrise sau autoadministrate)
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Avei n fiecare zi trei mese echilibrate ? _____________________________________________________
Dac
nu,
v
rugm
explicai
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Facei n mod regulat exerciii fizice ? Dac da, ce tip i ct de des ?
______________________________________________________________________________________
Subliniai oricare din elementele urmtoare care vi se potrivete dumneavoastr :
Marijuana
Tranchilizante
Sedative
Aspirin
Cocain
Analgezice
Alcool
Cafea
igri

stimulante
halucinogene (LSD,etc.)
diaree
constipaie
alergii
pusee de tensiune
probleme cardiace
greuri
vom

insomnie
dureri de cap
dureri de spate
treziri timpurii dimineaa
somn sntos(potrivit)
mncat excesiv
apetit srac
mese de proast calitate

Subliniai oricare din urmtoarele care se aplic membrilor familiei dvs.:

boli tiroidiene, boli de rinichi, astm, boli neurologice, boli infecioase, diabet, cancer, boli
gastrointestinale, probleme de prostst, glaucom, epilepsie, altele ___________________________

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Ai avut vreodat boli ale corpului sau pierderi de contiin ? V rugm dai detalii
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V rugm descriei orice operaie chirurgical pe care ai avut-o (dai date)
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Descriei orice fel de accidente sau traumatisme de care ai suferit (dai date)
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8. Istoria etapelor
V rugm subliniai (scriei) cele mai semnificative amintiri sau experiene de via corespunztoare
urmtoarelor etape de vrst:
0-5____________________________________________________________________________________________
6-11___________________________________________________________________________________________
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_

11-15 _________________________________________________________________________________________
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16-20 _________________________________________________________________________________________
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21-25 _________________________________________________________________________________________
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26-30 _________________________________________________________________________________________
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31-35 _________________________________________________________________________________________
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36-40 _________________________________________________________________________________________
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41-45 _________________________________________________________________________________________
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46-50 _________________________________________________________________________________________
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51-55 _________________________________________________________________________________________