DIRECTIA GENERALA DE ASISTENTA SSOCIALA SI PROTECTIA COPILULUI GALATI

Compartimentul...........................................

FIŞA DE EVALUARE INITIALA

I. DATE PERSONALE
1. Nume şi prenume……………………………………..………………………………
Data şi locul naşterii …………………………………….…………………………….
BI/CI seria……nr…………..
CNP ___/___/___/___/___/___/___/___/___/___/___/___/___/
Stare civilă_____________________
Studii_________________________Ocupaţia_______________________________
Etnia ______________________
Religia_________________________________________
Domiciliul____________________________________________________________
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2.Reprezentant legal_________________________________________________
BI/CI seria……nr……………….
CNP ___/___/___/___/___/___/___/___/___/___/___/___/___/
Domiciliul………………………………………………………………………………………

II. STAREA DE SĂNĂTATE PSIHO-FIZICĂ

Istoric medical
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Starea de sănătate actuală , grad de autonomie, dependente
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Profilul psihologic
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 DIRECTIA GENERALA DE ASISTENTA SSOCIALA SI PROTECTIA COPILULUI GALATI
Compartimentul...........................................

III. ISTORIC SOCIAL

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IV. ASPECTE PRIVIND MEDIUL DE VIAŢĂ

Locuinta_____________________________________________________________
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Utilitati______________________________________________________________
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Situatia financiara
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Relații sociale
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V. Servicii sociale de care a mai beneficiat / beneficiază de la alte organizaţii

/instituţii:
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VI. NEVOI IDENTIFICATE

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 DIRECTIA GENERALA DE ASISTENTA SSOCIALA SI PROTECTIA COPILULUI GALATI
Compartimentul...........................................

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VII. CONCLUZII ŞI RECOMANDĂRI
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Întocmit. ....................................functia..........................semnatura……………

Data : ………………..

Şef ………………….,

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