You are on page 1of 2

Anamnese Professor Mediador

DADOS PESSOAIS
Nome:____________________________________________ Srie/Ano:_______________
Nascimento ____/____/____ Idade: _____ anos Naturalidade:______________________
Endereo: _________________________________________________________________
Bairro:_______________________________ Cidade:______________________________
CEP: __________ Tel: ____________________ Cel: ____________________________
Pai: ______________________________________________________________________
Me: _____________________________________________________________________
Responsvel Legal: _________________________________________________________
QUEIXA
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Indicado para mediao por: ________________________________________________
Transcrio da 1 entrevista:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Transcrio das Orientaes do mediador:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
A mediao deve ser estendida at a famlia: ( )Sim ( ) No
Famlia convocada em ________/________/______________

Entrevista com a famlia:


Data: ______/______/___________
Pai compareceu ( ) Sim ( ) No
Me compareceu ( ) Sim ( ) No
Responsvel compareceu ( ) Sim ( ) No

Quem ? __________________________________________________________________
Relatos de situaes familiares que podem prejudicar o comportamento:
Nascimento de irmos: ( ) sim ( )no
Mudanas ( ) sim ( )no
Mortes ( )sim ( )no
De quem?
_________________________________________________________________________
Desempregos ( ) sim ( )no
Separaes ( ) sim ( ) no
Tem algum que o(a) protege? ( )sim ( )no
Quem? ___________________________________________________________________
muito censurado(a)? ( )sim ( )no
Relaciona-se bem com:
o pai ( )sim ( )no
a me ( )sim ( )no
os irmos ( )sim ( )no
Quem acompanha a vida escolar mais de perto?
_________________________________________________________________________
A famlia est passando por problemas no momento?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Relato da Mediao com pais/responsveis:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Orientao aos Pais:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Observaes:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
A criana/adolescente se encontra em situao de risco? ( ) Sim ( ) No
Encaminhamento:
( ) _______________________________________
( ) _______________________________________

Araraquara, , __________de_______________________________de20______.
_____________________________________________
Professor Mediador