Unitatea medicala*..…………………...

Dosar nr………………
Nr. de inregistrare……………………… Numele psihologului/psihopedagogului

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FIŞĂ PSIHOLOGICĂ

I. Date personale ale beneficiarului

Nume……………………………............................................................................................................
Prenume…………………………...........................................................................................................
Data şi locul naşterii…………...............................................................................................................

Tipul de dizabilitate…………………………………………………………………….................................
Dizabilităţi asociate…………………………………………………………………….................................
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II. Dezvoltarea psiho-motorie a beneficiarului

Dezvoltarea senzorial-perceptivă……………………………………………………….............................
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Nivelul dezvoltării psiho-motricităţii…………………………………………………..................................
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Nivel de dezvoltare intelectuală (Vârsta de dezvoltare,Coeficient de dezvoltare)-se precizează
testul / proba psihologică folosită
I. Gândirea (inclusiv nivelul operaţional)………………………………………...............................
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II. Memoria………………………………………………………………………..................................
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III. Atenţia………………………………………………………………………….................................
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Nivelul I de cunoaştere
Imaginaţia………………………………………………………………………………………………………
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Limbajul şi comunicarea………………………………………………………………................................
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Afectivitatea…………………………………………………………………………….................................
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Motivaţie………………………………………………………………………………...................................
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Temperament……………………………………………………………………………..............................
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Voinţa…………………………………………………………………………………...................................
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Atitudini………………………………………………………………………………....................................
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Aptitudini………………………………………………………………………………..................................
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Nivelul maturizării psiho-sociale
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Profilul psihologic………………………………………………………………………................................
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III. Recomandări psihologice

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Data………………………………………………...

Semnătura psihologului/psihopedagogului…………………………..........................

*NOTA: DOCUMENTUL VA CONTINE ŞTAMPILA INSTITUTIEI SI SEMNATURA REPREZENTANTULUI ACESTEIA