Complexul de Servicii Sociale Jibou

Nr. _______ din __________________

PROGRAM DE INTERVENŢIE SPECIALIZAT PENTRU RECREEREA ŞI

SOCIALIZAREA COPILULUI

Numele şi prenumele copilului: __________________________________________________

Numele cu care doreşte copilul să fie apelat: _________________________________________
Data naşterii: ____/____/_______
Adresă: _______________________________________________________________________
Naţionalitate: __________________________________________________________________
Etnie: ________________________________________________________________________
Religia: ______________________________________________________________________
Tipul de dizabilitate:
 Fizic
 Somatic
 Auditiv
 Vizual
 Psihic
 Neurologic
 Asociat
 Boli rare
 HIV/SIDA
Diagnostic:____________________________________________________________________
_____________________________________________________________________________
Persoana de referinţă: ____________________________________________________________

Numele specialistului care răspunde de plan Specializarea

Alte persoane implicate Specializarea Contact

Detalii despre intervenţiile necesare pentru a răspunde nevoilor identificate în Planul personalizat
de intervenţie, pentru:
 Sănătate:_______________________________________________________________
_______________________________________________________________________
 Nevoi fizice şi emoţionale: _________________________________________________
_______________________________________________________________________
 Cerinţe speciale de îngrijire: _______________________________________________
________________________________________________________________________

Data întocmirii, Data revizuirii, Data următoarei revizuiri,

____/____/_____ ____/____/_____ ____/____/______
 ACTIVITĂŢI RECREATIVE ŞI DE SOCIALIZARE
Activităţi zilnice
Data Activitatea Observaţii

Obiective pe termen scurt:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Obiective pe termen mediu:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Obiective pe termen lung:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
 ACTIVITĂŢI OCAZIONATE DE ANUMITE EVENIMENTE
Data Activitatea Observaţii

Obiective pe termen scurt:________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
Obiective pe termen mediu:_______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Obiective pe termen lung:_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

ACTIVITĂŢI PERIODICE
Data Activitatea Observaţii

Obiective pe termen scurt:________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

Obiective pe termen mediu:_______________________________________________________

______________________________________________________________________________
______________________________________________________________________________

Obiective pe termen lung:_________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EXTINDEREA RELAŢIILOR SOCIALE
Activitatea Persoane implicate Termen Observaţii

EVALUARE

Vârsta la care a fost pentru prima dată instituţionalizat ____________

Traseul instituţional
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Relaţia cu părinţii
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Relaţia cu colegii
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Interacţiunea cu persoana de referinţă
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Relaţia cu personalul
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Relaţia cu alte persoane
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Observaţii
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________