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CENTRUL JUDEEAN DE RESURSE I

ASISTEN EDUCATIONAL
TELEORMAN

CABINETUL DE ASISTEN PSIHOPEDAGOGIC

FI DE EVIDEN
Data:______________

Nr._____

I. Numele i prenumele:_____________________________________________________________
Vrsta:_________________________________________________________________________
Sex: ___________________________________________________________________________
Studii (profil):___________________________________________________________________
Mediul de provenien:____________________________________________________________
II. Profesia prinilor: mama ________________________________________________________
tata ___________________________________________________________
Tipul familiei:_____________________________________________________________________
III. Starea actual a sntii:________________________________________________________
Antecedente: __________________________________________________________________
IV. Motivul pentru care s-a prezentat la cabinetul de consiliere:
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Data

Activitatea desfurat

Profesor psiholog,

Interpretare/Observaii