Documente Academic
Documente Profesional
Documente Cultură
I. DATE GENERALE:
1. Nume: _______________________________________________________
2. Locul si data nasterii: __________________________________
3. Vârsta: ____________________ Sex: ________________________
4. Adresa si telefon:
________________________________________________________________
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5. Populație______________________________________________________
6. Stare civila____________________________________________________
7. Ocupaţie_____________________________________________________
8. Motivul consultării: ____________________________________________
9. Este prima ta abatere? Dar_____________________________________
1. Tatăl: ____________________________________________________
Vârsta: ___________
Ocupatie:
________________________________________________________
Dependențe:
_____________________________________________________
Relațiile cu subiectul în copilăria
sa:______________________________
________________________________________________________________
2. Mama: ____________________________________ Vârsta: __________
Ocupatie:
________________________________________________________
Dependențe:
_____________________________________________________
Relațiile cu subiectul în copilăria
sa:______________________________
________________________________________________________________
3. Relații: bune, regulate, rele, despărțite, divorțate, abandonarea
totală a unui membru.
Precizați motivele:
________________________________________________
________________________________________________________________
4. Frați: sex și vârstă: ____________________________________
________________________________________________________________
________________________________________________________________
Relații cu ei: stabile, instabile, conflictuale, mult, pu țin, fără
comunicare.
5. Fundal de familie:
Medici:
________________________________________________________________
________________________________________________________________
________________
Psihiatrie:
________________________________________________________________
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Toxic:
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6. Reacția rudelor la problema subiectului:
________________________________________________________________
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2. Nivel de instruire :
Scoala:
____________________________________________________________
Burlac________________________________________________________
Universitate_____________________________________________________
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4
Ce te face nervos?:
________________________________________________
4. Interese si pasiuni:
4
5
5. Dezvoltare psihosexuală:
Aveți un partener?:
__________________________________________________________
Schimbați frecvent partenerii?
________________________________________________
Familia vă acceptă partenerul?
________________________________________________
6. Simptome nevrotice:
Coșmaruri: __________
Somnambulism: _____________
Regresii: ________________
Umezirea patului: ________________________
Encopresis: _________________
Onicofagie: _____________________
Trichotilomania: ______________
Probleme de limba: ______________
Căpușe: ________________________
Convulsii: __________________
Furt: _______________________
Minciună: _______________________
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6
7. Pedepsele:
Poti suporta
pedeapsa?:________________________________________________________
________
___________________________________________________________________
Ce nu poți suporta în ceilalți?_________________________________
___________________________________________________________________
Crezi că este corect să te pedepsească dacă meriți?
________________________
___________________________________________________________________
8. antecedente penale:
__________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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9. Observații finale:
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