CENTRO DE PSICOLOGIA APLICADA

CAMPUS ALPHAVILLE

PRONTUÁRIO Nº _____

Disciplina: Psicoterapias
Estágio: Psicoterapia de Orientação Psicanalítica

Objetivo: Realização de atendimento clínico individual supervisionado na orientação

psicanalítica visando o aprimoramento clínico da capacidade de diagnosticar e manejar as
situações de sofrimento psíquico a partir do referencial proposto.

DADOS DE IDENTIFICAÇÃO DO USUÁRIO

Nome: _____________________________________________________________________
Data do Nascimento: ___/___/___
Histórico dos atendimentos no CPA: _______________________________________
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EVOLUÇÃO DO ATENDIMENTO ATUAL

Queixa:_____________________________________________________________________
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Data___/___/___
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Alameda Amazonas, 492 – Alphaville – Barueri – SP – CEP.: 06454-070
Fone/Fax: 4191-1078
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Alameda Amazonas, 492 – Alphaville – Barueri – SP – CEP.: 06454-070
Fone/Fax: 4191-1078
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Encaminhamento:
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Estagiário (a): ________________________ Estagiário (a): ________________________

Ass: ________________________________ Ass: _______________________________

RA: ________________________________ RA: _______________________________

Supervisora: Luciana Goldman Coordenadora:

Ass: ________________________________ Ass: ______________________________

CRP: 06/35421 CRP: _____________________________

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Alameda Amazonas, 492 – Alphaville – Barueri – SP – CEP.: 06454-070
Fone/Fax: 4191-1078