ENTREVISTA INICIAL FAMILIAR

DATA ___/___/_____
QUESTÕES GERAIS
Nome da constituição familiar: ______________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Data de nascimento dos membros: ____________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Endereço:________________________________________________________________________
Cidade:_____________________________________Telefone:_____________________________
Idade dos membros:________________________________________________________________
________________________________________________________________________________
Estado civil:_____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Escolaridade:_____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Ocupação:_______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Religião:_________________________________________________________________________
Telefone em caso de necessidade: ( ) ____________________________________________
De quem é este telefone? ___________________________________________________________

1
Como se constitui a moradia da família? (Mencionando grau de parentesco)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Vocês moram em: ( ) Casa ( )Apartamento ( ) Outro______________________

1. QUESTÕES CLÍNICAS
1.1 Quais os motivos que levaram a família a procurarem acompanhamento psicológico familiar?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
1.2 Desde quando a família têm vivido estas dificuldades? Quais prejuízos encontrados por vocês
de maneira individualizada desde que o conflito se instalou?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
1.3 A família já consultou algum profissional da psicologia ou outra área em relação a esta
dificuldade? O que realizaram para modificar o quadro?
________________________________________________________________________________
________________________________________________________________________________

2
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2 DADOS RELEVANTES

2.1 Quais as atitudes de suas famílias extensas em relação à dificuldade que vocês vêm
enfrentando?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2.2 Algum membro da família utiliza alguma medicação de uso contínuo? Qual (is) Para que?
________________________________________________________________________________
________________________________________________________________________________
3 DADOS
3.1 Algum membro utiliza alguma droga lícita ou ilícita?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3.2 Vocês já pensaram em fazer algo contra as suas próprias vidas ou a de terceiros?
( ) Não ( ) Sim. Explique.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3.3 Com relação à família extensa de vocês, algum membro apresenta histórico de: psicose,
consumo de drogas, internações psiquiátricas, delinquência, alcoolismo, tentativa de suicídio?
Quem?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

3
3.4 Descrevam como é a família. (comportamentalmente e emocionalmente).
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3.5 Fale um pouco sobre a rotina semanal da família (trabalho, lazer, estudo, etc). Possuem rede de
apoio, vida social, hobbies?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

3.6 Como é a alimentação, sono e atividades físicas de cada membro familiar? São feitos exames de
rotina usualmente, como Check-up?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

4
3.7 Fale um pouco sobre a história da família. Como ela se constituiu?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________________________________________________________________________

3.8 Construção do Genograma familiar, a partir dos avós:

Genograma Materno Genograma Paterno

___________________ ___________________

5
 Genograma da família atual

Impressões gerais a cerca dos comportamentos da família:

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

______________________________
James Rodrigo Felippe
Psicólogo Clínico CRP 12/20836