Cabinet Individual de Psihologie Mafteiu Doina Cristina

Bd. C. Ressu, nr. 4, tel. 0724518161, e-mail doinamafteiu@yahoo.com

RAPORT DE PSIHODIAGNOSTIC SI EVALUARE CLINICA

I. Informaţii despre pacient:

• Nume si prenume:
Data nasterii: Adresa:

Diagnostic medical:

II. Obiectivul psihodiagnosticului şi evaluării:

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III. Descrierea succintă a componentelor psihologice

Nivel Subiectiv/Emoţional (inclusiv Satisfacţia/Calitatea vieţii)

Ce s-a evaluat? Cu ce s-a evaluat?
(teste/sarcini/probe şi/sau interviuri)

 Nivel Cognitiv
Ce s-a evaluat? Cu ce s-a evaluat?
(teste/sarcini/probe şi/sau interviuri)

 Nivel comportamental
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 Ce s-a evaluat? Cu ce s-a evaluat?
(teste/sarcini/probe şi/sau interviuri)

 Nivel psihofiziologic

Ce s-a evaluat? Cu ce s-a evaluat?

(teste/sarcini/probe şi/sau interviuri)

 Nivel de personalitate şi Mecanisme Defensive/Adaptare

Ce s-a evaluat? Cu ce s-a evaluat?

(teste/sarcini/probe şi/sau interviuri)

 Nivel de relaţionare interpersonală (inclusiv, de cuplu, familie, grup

etc.)

Ce s-a evaluat? Cu ce s-a evaluat?

(teste/sarcini/probe şi/sau interviuri)

IV. Concluzii :
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V. Recomandări:

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Data evaluarii Psiholog

(semnatura si parafa)