FORMULAR APP

Clasa:
Şcoala:

1. Date factuale:
Numele şi prenumele:__________________________________________________
Data naşterii:_________________________________________________________
Numele şi prenumele/ studii:
-tata_______________________________________________________________
-mama_____________________________________________________________
Ocupaţia actuală a părinţilor:
-tata_______________________________________________________________
-mama_____________________________________________________________
2. Factori legaţi de familie:
Structura familiei:_____________________________________________________
Situaţia materială a familiei:_____________________________________________
Relaţii interpersonale cu membrii familiei :_________________________________
____________________________________________________________________
____________________________________________________________________
Situaţii deosebite în familie:_____________________________________________
____________________________________________________________________
____________________________________________________________________
3. Factori legaţi de şcoală:
Prezenţa la cursuri (ore)_________________________________________________
____________________________________________________________________
Performanţe şcolare:___________________________________________________
____________________________________________________________________
Comportamentul manifestat în mediul
şcolar:________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Relaţii interpersonale:
-cu colegii_____________________________________________________
____________________________________________________________________
-cu dirigintele__________________________________________________
____________________________________________________________________
-cu profesorii_________________________________________________
______________________________________________________________________
4. Influenţa mass-mediei şi a grupurilor stradale:
 Frecvenţa grupurilor stradale:_____________________________________________
______________________________________________________________________
Componenţa grupurilor stradale: ____________________________________________
______________________________________________________________________

5. Definirea problemei:

6. Demersul intervenţiei:
Obiective Nr. Metode/instrumente utilizate
Şedinţei
1.

2.
3.

4.

5.

7. Evaluarea eficienţei intervenţiei

NOTA: Exemple obiective:
-construirea relaţiei
-identificarea problemei
-pozitivarea imaginii de
sine -testare psihologica
-stabilirea profilului psihologic
- etc.........