Anexa nr.

4
Fișa de evaluare psiho-socială a solicitanţilor
1. Solicitant:
Dna
Nume şi prenume______________________________________________________________
Data şi locul naşterii ____________________________________________________________
Studiile (nivelul cel mai înalt al studiilor_____________________________________________
Profesia, ocupaţia şi locul de muncă_________________________________________________
Domiciliul ____________________________________________________________________
Dnul
Nume şi prenume _______________________________________________________________
Data şi locul naşterii___________________________________________________________
Pregătirea şcolară/profesională_____________________________________________________
Profesia, ocupaţia şi locul de muncă ________________________________________________
Domiciliul_____________________________________________________________________

2. Biografia succintă a solicitanţilor

Dna __________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Dnul_________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

3. Istoria cuplului
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4. Stilul de viaţă al familiei
Puncte tari (resurse)__________________________________________________________
__________________________________________________________________________
Puncte slabe________________________________________________________________
__________________________________________________________________________
5. Interese și necesități (spirituale,materiale, de cunoaștere etc.)

SOȚ SOȚIE

__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________

6. Caracteristici de atitudine ( fașă de muncă, oameni, valori etc.)

SOȚ SOȚIE

__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________

7. Caracteristici de comportament ( comunicabil, echilibrat, agresiv)

SOȚ SOȚIE
__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________

8. Caracteristici de temperament ( melancholic, coleric, flegmatic,sangvinic)

SOȚ SOȚIE

__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________

9. Autoaprecierea

SOȚ SOȚIE

__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________

10. Alte caracteristici

SOȚ SOȚIE

__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________
__________________________________ ____________________________________

11. Relațiile în cadrul cuplului (climatul intrafamilial, comunicare/inter-relaționare, modul de

rezolvare a conflictelor/divergențelor de opinie, capacitatea de a se adapta situațiilor noi)

Puncte tari( resurse)

_____________________________________________________________________________
_____________________________________________________________________________
Puncte slabe
_____________________________________________________________________________
_____________________________________________________________________________
12. Descrierea dinamica relației de cuplu a solicitanților

12.1 durabilitatea prezentei relații

_____________________________________________________________________________
_____________________________________________________________________________

12.2. felul în care solicitanții fac față dificultăților

_____________________________________________________________________________
_____________________________________________________________________________

12.3. felul în care sunt luate deciziile în cadrul familiei

_____________________________________________________________________________
_____________________________________________________________________________

12.4. repartizarea rolurilor în familie

_____________________________________________________________________________
_____________________________________________________________________________
13. Relația dintre solicitanți și persoanele care locuiesc în aceiași locuință/gospodărie
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

14. Relația dintre persoanele adulte și copii care locuiesc în aceiați locuință/gospodărie
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

15.Caracteristici și modalitatea de relaționare cu părinți

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Puncte tari(resurse)
_____________________________________________________________________________
_____________________________________________________________________________
Puncte slabe
_____________________________________________________________________________
_____________________________________________________________________________

16. Caracteristici și modalitatea de relaționare cu membrii familiei extinse

_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________

17. Atitudinea părinților/surorilor solicitanților față de adopția unui copil de către aceștea
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________

18.1 Descrieți relațiile stabilite între membrii familiei solicitanților și vecini

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

18.2. Descrieți relațiile dintre familia solicitanților și instituțiile sociale comunitare

18.2.1. primărie
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

18.2.2. serviciul medical

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
18.2.3. școală/grădiniță
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

18.2.4. biserica
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

18.2.5. alte instituții sociale comunitare

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

19. Motivația pentru a adopta

Puncte tari (resurse)

_____________________________________________________________________________
_____________________________________________________________________________
Puncte slabe
_____________________________________________________________________________
_____________________________________________________________________________

20. Așteptările privid adopția ( inclusive reprezentările în legătură cu familia biologică a

”copilului adoptabil”)

Puncte tari (resurse)

_____________________________________________________________________________
_____________________________________________________________________________
Puncte slabe
_____________________________________________________________________________
_____________________________________________________________________________

21. Așteptările față de copilul adoptive:

21.1. vârsta copilului __________________ ani;

21.2.sexul copilului __________________;

21.3 personalitate copilului

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
21.4. starea de sănătate a copilului
_____________________________________________________________________________
_____________________________________________________________________________

22. Disponibilitatea pentru adopția mai multor copii concomitant (da/nu) ____ nr _______;

23. Capacitatea parentală

Puncte tari (resurse)

_____________________________________________________________________________
_____________________________________________________________________________
Puncte slabe
_____________________________________________________________________________
_____________________________________________________________________________

24. Sinteza informației

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

25. Concluzii generale și recomandări privind capacitatea de adopție a solicitanților

25.1.Concluzii:_________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

25.2. Recomandări:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Psiholog ( numele și prenume) : __________________________________________________

Semnătura: ___________________________________________________________________

Instituția: ____________________________________________________________________

Data_________________________________________________________________________