ENTREVISTA

Dados de identificação:
Nome:__________________________________________________________
Data de nascimento: _____/______/______ Idade:____________
Escolaridade: __________________ Estado civil: _______________________
Profissão: _______________________________________________________

Dados sobre os pais:

Problemas de saúde:______________________________________________
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Acompanhamento psicológico / queixa / resultados:______________________

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Ingestão de substâncias entorpecentes (tipo, data de início do uso, quantidade,

frequência em que se dá a ingestão), interferência na vida pessoal: _________
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História de vida dos pais: ___________________________________________

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Relacionamento conjugal dos pais na infância: __________________________
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Dados sobre o paciente:

Problemas de saúde:______________________________________________
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Acompanhamento psicológico / queixa / resultados: ______________________

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Ingestão de substâncias entorpecentes (tipo, data de início do uso, quantidade,

frequência em que se dá a ingestão), interferência na vida pessoal: _________
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Com quem reside atualmente:_______________________________________

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Atividades de lazer que realiza: _____________________________________
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Recordações sobre a sua juventude: _________________________________

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Relação com cada um de seus pais: __________________________________

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Pessoas significativas em sua trajetória de vida: ________________________

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Perdas significativas:______________________________________________
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Relacionamento com cônjuge / vida amorosa, novos relacionamentos? ______

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Qualidade da relação com a família de seu EX.: ________________________

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Já houve momentos de crise no relacionamento? Brigas / Agressões?

Permaneceram separados em algum momento? ________________________
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Qual costumava ser o motivo? _____________________________________

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Qual o motivo da separação? _______________________________________

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Tem filhos? Quantos? Aos cuidados de quem? Idades?

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Saúde:
Doenças:________________________________________________________
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Idade:__________________________________________________________
Hospitalizações:__________________________________________________
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Cirurgias:________________________________________________________
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Vacinas:________________________________________________________
Medicamentos atuais:______________________________________________
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Acompanhamentos atuais:__________________________________________
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Antecedentes patológicos da família:__________________________________
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Situações que motivaram o encaminhamento para a avaliação:

Você pode contar como foi na última vez em que isto ocorreu? _____________
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Quando isto acontece, como você se sente? ___________________________
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O que sabe sobre os fatos/motivos? __________________________________

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Como isto tem atrapalhado a sua vida? _______________________________

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Como você tem feito para lidar com esta situação? ______________________
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Providências tomadas? ____________________________________________

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O que você espera da terapia? _____________________________________

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Quais seus objetivos e metas? ______________________________________

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Considerações do entrevistador (aparência do cliente, comportamentos durante

a sessão…) _____________________________________________________
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