FICHA DE ENTREVISTA DIAGNÓSTICA

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FICHA DE ENTREVISTA DIAGNÓSTICA
I. DADOS SOCIODEMOGRÁFICOS E DE SAÚDE
Nome: __________________________________________________________________
Endereço:_______________________________________________________________
Telefone: _____________________________ E-mail:____________________________
Sexo: ( ) F ( )M Idade: ________ Data de Nascimento:____/____/_____
Naturalidade:____________________ Escolaridade:______________________ 
Religião: ________________________ Estado Civil:_______________________
Ocupação: ______________________ Plano de Saúde:____________________
Fontes de referência : _____________________________________________________
Reside com quem:
	NOME
	PARENTESCO
	IDADE
	ESCOLARIDADE
	OCUPAÇÃO
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
Uso de Medicamentos: __________________________________________________________________________________________________________________________________________________________
Doenças prévias: __________________________________________________________________________________________________________________________________________________________
Experiência Prévia com Psicoterapia: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Risco de Suicídio: ______________________________________________________________
Risco para Terceiros:____________________________________________________________
II. HISTÓRIAS PESSOAIS
Genograma: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Doenças Físicas e/ou Mentais Prévias na Família: __________________________________________________________________________________________________________________________________________________________
Infância: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Adolescência: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Idade Adulta: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
III. QUEIXAS ATUAIS E SEUS INÍCIOS:
Motivação para buscar psicoterapia agora: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
História das queixas principais: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Expectativas em relação à psicoterapia: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
IV. APRESENTAÇÃO ATUAL E EXAME MENTAL
Aparência geral: __________________________________________________________________________________________________________________________________________________________
Estado afetivo: ________________________________________________________________
Humor: ______________________________________________________________________
Memória:_____________________________________________________________________
Linguagem:____________________________________________________________________
Teste de realidade:______________________________________________________________
Qualidade do sono: __________________________________________________________________________________________________________________________________________________________
V. TÓPICOS DE CONCLUSÃO:
Consegue pensar em alguma informação importante que não tenha sido abordada e queira acrescentar¿ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Gostaria de perguntar algo¿ __________________________________________________________________________________________________________________________________________________________
Como sentiu-se com a nossa conversa¿ __________________________________________________________________________________________________________________________________________________________VI. ADESÃO À PSICOTERAPIA:
Contrato terapêutico: __________________________________________________________
Freqüência:______________________ Valor da sessão: _____________________________
Forma de pagamento: __________________________________________________________
VII. INFERÊNCIAS: ( preenchimento pós - sessão)
Temas mais recorrentes: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Padrão de apego, áreas de aprisionamento do desenvolvimento e de conflito interno:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Defesas predominantes: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Fantasias inconscientes inferidas, desejos, medos e crenças: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Identificações centrais e contraidentificações: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Lutos negados: __________________________________________________________________________________________________________________________________________________________
Autocoesão e autoestima: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Vínculo terapêutico: ____________________________________________________________________________
Observações: