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42 ♦ Deborah Dobson e Keith S. Dobson QUADRO 3.1 Folha para formulação cognitivo-comportamental de caso Nome: _________________________________________________ Data: ____________________________ Informações de identificação: ________________________________________________________________ Lista de problemas: 1. _______________________________________________________________________________________ 2. _______________________________________________________________________________________ 3. _______________________________________________________________________________________ 4. _______________________________________________________________________________________ 5. _______________________________________________________________________________________ Diagnósticos: Eixo I: ___________________________________________________________________________________ Eixo II: ___________________________________________________________________________________ Eixo III: __________________________________________________________________________________ Eixo IV: __________________________________________________________________________________ Eixo V: Avaliação de funcionamento global _____________________________________________________ Medicações: ______________________________________________________________________________ Crenças nucleares hipotéticas: Eu sou ___________________________________________________________________________________ Os outros são _____________________________________________________________________________ O mundo é _______________________________________________________________________________ O futuro é ________________________________________________________________________________ Situações precipitadoras/ativadoras: __________________________________________________________ _________________________________________________________________________________________ Hipóteses de trabalho: ______________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Origens de desenvolvimento: ________________________________________________________________ _________________________________________________________________________________________ Plano de tratamento/metas: 1. ______________________________ 2. ____________________________ 3. ______________________________ 4. ____________________________ 5. ______________________________ 6. ____________________________ Obstáculos potenciais às metas: ______________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Auxílios potenciais às metas: ________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Dobson_03.indd 42Dobson_03.indd 42 18/06/10 16:4218/06/10 16:42