CMINUL PENTRU PERSOANE VRSTNICE SIBIU

SIBIU, STR. GEORGE COBUC NR. 20

FI DE EVALUARE INIIAL

Numele i prenumele beneficiarului:__________________________________________

Vrsta:__________________________________________________________________
Studii:__________________________________________________________________
Stare civil:______________________________________________________________
Adresa beneficiarului:______________________________________________________
Aparintori:_____________________________________________________________
Persoan de contact in caz de urgen
Nume i prenume:_________________________________________________________
Numr de telefon:_________________________________________________________
Adresa:_________________________________________________________________
Gradul de rudenie cu beneficiarul:____________________________________________
Motivul internrii:________________________________________________________
________________________________________________________________________
Tipul cazului:
-

Abandon
Neglijare / abuzz
Persoane singure ,vrstnici
Persoane cu nevoi speciale
Violen domestic
Alte situaii__________________________________________________________