FICHA DE ATENDIMENTO PSICOLÓGICO EM ENSINO SUPERIOR

Data: _____/_____/_____ Nº de Registro: _____________

PSICÓLOGA RESPONSÁVEL: ___________________________________________________

DADOS PESSOAIS DO DISCENTE

Nome:__________________________________________________________________________
Estado Civil:________________________ D. N._____/_____/______ Idade:__________________
Endereço:________________________________________________________________________
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Bairro:_____________________ Município:_________________________ Cep:______________
Telefone fixo:___________________________Celular:___________________________________
Residência: ( ) Própria ( ) Alugada ( ) Cedida ( ) Ocupada ( ) Outros ________________
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Campus: ________________________________ Curso:__________________________________
Ano de entrada:_______________________ Semestre atual:_______________________________
Profissão e/ou estágio: _____________________________________Renda mensal:____________
Possui auxílio estudantil? ( ) Não ( ) Sim. Qual? ______________________________________

DADOS SOBRE SAÚDE

Grupo sanguíneo:__________________________________________________________________
Faz tratamento de saúde? ( ) Não ( )Sim. Qual? ______________________________________
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Faz uso de medicação? ( ) Não ( )Sim. Qual? ________________________________________
Possui Plano de Saúde? ( ) Não ( )Sim. Qual? _______________________________________
Faz acompanhamento Odontológico? ( ) Não ( ) Sim. Qual? ____________________________
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Necessita de atendimento educacional especializado? ( ) Sim ( )Não. Em caso afirmativo, indique
as especificidades: ________________________________________________________________

COMPOSIÇÃO FAMILIAR
 Nome Idade Parentesco Profissão Renda mensal P.N.E.

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ENCAMINHAMENTO
( ) Demanda espontânea
( ) Encaminhada. Qual profissional ou setor? ________________________________________

QUEIXA PRINCIPAL
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EVOLUÇÃO DA QUEIXA
- Início da Queixa:
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- Súbita ou Progressiva:
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- Quais mudanças ocorreram/ O que afetou:
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- Sintomas:
( ) Não ( ) Sim. Quais?
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QUEIXAS SECUNDÁRIAS
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RELACIONAMENTO FAMILIAR
Dinâmica Familiar:
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Eventos Significativos:
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Rede de Apoio:
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HISTÓRICO SOCIAL
Hábitos de Lazer:
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Vida Social:
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Inserção em Grupos:
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Rede de Apoio:
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DADOS ESCOLARES
Casos de Reprovação:
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Áreas de Dificuldade:
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Hábitos de Estudo:
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ORIENTAÇÕES E ENCAMINHAMENTOS
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CONSIDERAÇÕES FINAIS
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EVOLUÇÃO
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