MIHALCEA FLORINELA - CABINET INDIVIDUAL DE PSIHOLOGIE

CPR 1BV1975/2010 , CIF 27801370, CUP 08642

Cabinetul psihologic este operator de date cu caracter personal inregistrat la ANSPDCP cu nr.19434

V rugm s completai toate rubricile de pe pagin i s citii cu atenie toate indicaiile!

FISA CONSILIERE
INDIVIDUALA

Psiholog, Florinela Mihalcea

CUP 08642

BRASOV, 2013

AVETI OBLIGATIA SA TRATATI CU MAXIMA CONFIDENTIALITATE ACEASTA EVALUARE

MIHALCEA FLORINELA - CABINET INDIVIDUAL DE PSIHOLOGIE

CPR 1BV1975/2010 , CIF 27801370, CUP 08642
Cabinetul psihologic este operator de date cu caracter personal inregistrat la ANSPDCP cu nr.19434

V rugm s completai toate rubricile de pe pagin i s citii cu atenie toate indicaiile!

I.

Fisa initiala a cazului

Culegerea datelor anamnestice, clinice si paraclinice
Modalitatea solicitarii : on-line

Solicitant: titularul solicitrii

Numele si prenumele: ____________________________________________________
Mediul de proveninen : rural__, urban____, nr. telefon ____________________
Adresa de e-mail:_____________________________________fax:________________
Data solicitrii: ____________________________

Tipul cazului / situaiei : consiliere si evaluare psihologic

( relatati cu exactitate si folisti cuvintele dvs cu privire la cum v simtiti, etc. )

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Cum este viata dvs. actuala cu problemele identificate ? _____________________

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Date despre beneficiarul serviciilor psihologice:

Numele si prenumele :________________________________________________
Sexul: ___

Vrsta : ____ Domiciliul actual: ____________________________

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Date despre familia de origine:________________________________________________
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AVETI OBLIGATIA SA TRATATI CU MAXIMA CONFIDENTIALITATE ACEASTA EVALUARE

MIHALCEA FLORINELA - CABINET INDIVIDUAL DE PSIHOLOGIE

CPR 1BV1975/2010 , CIF 27801370, CUP 08642
Cabinetul psihologic este operator de date cu caracter personal inregistrat la ANSPDCP cu nr.19434

V rugm s completai toate rubricile de pe pagin i s citii cu atenie toate indicaiile!

De cine din familie v-ati simtit mai apropiat?____________________________________

Pentru c__________________________________________________________________
Cum a fost ptr dvs. sa fiti copil in familia dvs. de origine ?_________________________
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Date despre familia actual( expuneti ct mai multe date relevante):
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Informaii relevante despre traiul curent :
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Statut social i profesional:_____________________________________________

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Traseu educaional:___________________________________________________

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AVETI OBLIGATIA SA TRATATI CU MAXIMA CONFIDENTIALITATE ACEASTA EVALUARE

MIHALCEA FLORINELA - CABINET INDIVIDUAL DE PSIHOLOGIE

CPR 1BV1975/2010 , CIF 27801370, CUP 08642
Cabinetul psihologic este operator de date cu caracter personal inregistrat la ANSPDCP cu nr.19434

V rugm s completai toate rubricile de pe pagin i s citii cu atenie toate indicaiile!

Hobby-uri ( activitati, preocupri ce v creaz placere): _______________________________

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Avei permis auto ? _____, in ce an l-ati obtinut?___________, cum a fost ?________
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Ce motiv v-a determinat sa obtineti permis de conducere auto ? _________________
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Notati cursuri ce le-ati urmat ? ____________________________________________
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Atunci cnd erati mic() ce doreati sa deveniti cnd cresteti?_________________

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Religie :______________________difera de cea din copilarie?________________

Evaluarea strii de sntate- medicatie (daca e cazul si urmati un anumit tratament

medicamentos, pentru ce anume, tipul medicamentelor, etc. ):

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Tipul de spitalizare/internare ( date despre ultima internare, dac e cazul) : urgent____, medic
de familie___, medic specialist____, alte situaii _________________________________
Motivul spitalizrii/internrii: _______________________________________________
Perioada:__________________

Istoricul bolii ( dac este cazul):

Debut :__________________________________________________________________
AVETI OBLIGATIA SA TRATATI CU MAXIMA CONFIDENTIALITATE ACEASTA EVALUARE

MIHALCEA FLORINELA - CABINET INDIVIDUAL DE PSIHOLOGIE

CPR 1BV1975/2010 , CIF 27801370, CUP 08642
Cabinetul psihologic este operator de date cu caracter personal inregistrat la ANSPDCP cu nr.19434

V rugm s completai toate rubricile de pe pagin i s citii cu atenie toate indicaiile!

Evoluie:_________________________________________________________________
Diagnosticul a fost dat de:____________________________________________________

Antecedente personale fiziologice:

Sarcina ( nr. lor si la ce vrsta ):___________________________________________________

Intreruperi de sarcina:________Cauza:________________________________________
Nasterea dvs. ( cteva date despre cum a fost momentul nasterii dvs. ):___________________________
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Al ctelea nscut suntei in famila dvs.?________________________________________
Vaccinari:_________________________________________________________________
Alimentatia dvs. pna la vrsta de 3 ani:_______________________________________
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Alimentatia dvs . actual:____________________________________________________
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Evolutia ponderala:_________________________________________________________
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Achizitii neuropsihomotorii ( cnd ati nceput s mergei de-a busilea, in picioare, sa utilizati olita, sa silabisiti
primele cuvinte si care au fost acelea, etc. toate informatiile privind dezvoltarea dvs pn la vrsta de 6 ani):____________
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Colectivitate ( date despre perioada gradinitei, vrsta dvs si impresiile din acea perioad ):______________________
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Rezultate scolare, profesionale:_______________________________________________

AVETI OBLIGATIA SA TRATATI CU MAXIMA CONFIDENTIALITATE ACEASTA EVALUARE

MIHALCEA FLORINELA - CABINET INDIVIDUAL DE PSIHOLOGIE

CPR 1BV1975/2010 , CIF 27801370, CUP 08642
Cabinetul psihologic este operator de date cu caracter personal inregistrat la ANSPDCP cu nr.19434

V rugm s completai toate rubricile de pe pagin i s citii cu atenie toate indicaiile!

__________________________________________________________________________
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Rezultate , realizri personale:________________________________________________
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Antecedente personale patologice ( boli avute inclusiv bolile copilriei, interventii medicale, operatii, etc) :
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Antecedente patologice familiale (date medicale despre membrii familiei de origine):______________
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Conditii de viata in copilarie:____________________________________________

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Conditii actuale de viata si de munca:_____________________________________

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Situatia prezenta ( cteva date depre situatia dvs curent) :___________________________

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Evaluarea situaiei prezentate ( evaluati situatia curent in care v aflati ):_______________

AVETI OBLIGATIA SA TRATATI CU MAXIMA CONFIDENTIALITATE ACEASTA EVALUARE

MIHALCEA FLORINELA - CABINET INDIVIDUAL DE PSIHOLOGIE

CPR 1BV1975/2010 , CIF 27801370, CUP 08642
Cabinetul psihologic este operator de date cu caracter personal inregistrat la ANSPDCP cu nr.19434

V rugm s completai toate rubricile de pe pagin i s citii cu atenie toate indicaiile!

__________________________________________________________________________
__________________________________________________________________________

Alte date relevante despre dvs. ( in cazul in care am omis ceva, notati si alte informatii):

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Motivul solicitarii serviciului psihologic: __________________________________

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Observatii personale cu privire la asteptrile dvs. in legtura cu servicilu

solicitat:___________________________________________________________________
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Ati mai apelat pn acum la servicii psihologice ?____in ce perioada___________

pentru ce motiv ? ___________________________________________________________

Notati opinia cu privire la serviciile psihologice primite ( dac e cazul ) : _______

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Notati 3 (trei) caracteristici personale ( descrieti-va in minim trei cuvinte ) :____________

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Care sunt valorile dup care v ghidati in viat?

___________________________

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AVETI OBLIGATIA SA TRATATI CU MAXIMA CONFIDENTIALITATE ACEASTA EVALUARE

MIHALCEA FLORINELA - CABINET INDIVIDUAL DE PSIHOLOGIE

CPR 1BV1975/2010 , CIF 27801370, CUP 08642
Cabinetul psihologic este operator de date cu caracter personal inregistrat la ANSPDCP cu nr.19434

V rugm s completai toate rubricile de pe pagin i s citii cu atenie toate indicaiile!

Completati un motto personal:___________________________________________

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Ce v doriti cel mai mult de la viat, ce scopuri aveti ? ______________________

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Care este contributia dvs. in atingerea scopurilor precizate? _________________

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Cum ar fi viata dvs. far problemele actuale? _____________________________

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Alte informatii ( daca e cazul) :______________________________________________

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Client :_____________________________
Semnatura :_________________________
Completat la data de :_________________

AVETI OBLIGATIA SA TRATATI CU MAXIMA CONFIDENTIALITATE ACEASTA EVALUARE

MIHALCEA FLORINELA - CABINET INDIVIDUAL DE PSIHOLOGIE

CPR 1BV1975/2010 , CIF 27801370, CUP 08642
Cabinetul psihologic este operator de date cu caracter personal inregistrat la ANSPDCP cu nr.19434

V rugm s completai toate rubricile de pe pagin i s citii cu atenie toate indicaiile!

Va multumim !

AVETI OBLIGATIA SA TRATATI CU MAXIMA CONFIDENTIALITATE ACEASTA EVALUARE