INTERVIU CUNOASTERE

INTERVIU CUNOASTERENUMELE SI PRENUMELE ____________________________________ Vrsta ___________________Subliniai ceea ce se potrivete copilriei/ adolescenei dvs.:

Copilrie fericit probleme medicale

Copilrie nefericit probleme colare

Probleme legale probleme familiale

Probleme educaionale convingeri religioase puternice

Probleme comportamentale abuz de drog

Abuz de alcool altele_____________________________________Care este nlimea dvs.?__________Care este greutatea dvs.?_________Ai fost vreodata spitalizat pentru probleme psihiatrice?

Da(detalii)____________________________________________________________________________________

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Avei medic de familie?

Da (nume, nr. de telefon)_________________________________________________________________________Nu

Ai avut tentative suicidare?

Da(detalii context, consecine)_____________________________________________________________________

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Nu

Sufer cineva din familia dvs. de: alcoolism___________________________________________________________ depresie__________________________________________________________________ epilepsie__________________________________________________________________

orice altceva care poate fi considerat,,tulburare mental? ______________________________________________

_______________________________________________________________________________________________A avut / comis vreo rud tentativa de suicid?__________________________________________________________A avut / are vreo rud probleme cu legea?____________________________________________________________Analiza, pe modaliti, a problemelor dvs. actuale

Seciunea urmtoare este conceput pentru a v ajuta s v descriei problemele curente n detaliu i pentru a le identifica pe cele care ar putea trece neobservate. Aceasta ne va permite s concepem un program de asistare cuprinztor i adaptat nevoilor dvs. specifice.

1. Comportament

Subliniai fiecare din comportamentele urmtoare care v caracterizeaz:

Supraalimentaie retragere

Consum de droguri ticuri nervoase

Vom dificulti de concentrare

Comportament ciudat tulburri de somn

Consum prea mare de butur evitare fobic

Munc prea mult/ grea incapacitate de a desfura un anumit

Amnare tip de munc (mutri frecvente)

Reacii impulsive insomnie

Pierderea controlului lene

Asumare a prea multor riscuri probleme de alimentaie

Tentative suicidare comportament agresiv

Compromisuri plns

Fumat

Izbucniri de furie (ieit din srite)

Exist comportamente, aciuni sau obiceiuri pe care ai dori s le schimbai?____________

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Care sunt talentele/ aptitudinile/ abilitile cu care v mndrii? _____________________________________________________________________________________________________________________

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Ce ai vrea s facei mai mult?____________________________________________________________

Ce ai vrea s facei mai puin?___________________________________________________________

Ce ai vrea s ncepei s facei?__________________________________________________________

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Ce ai vrea s ncetai s mai facei? ______________________________________________________

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Cum v petrecei timpul liber?____________________________________________________________

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______________________________________________________________________________________n compania cui?(detalii anturaj) __________________________________________________________

______________________________________________________________________________________V meninei ocupat n mod compulsiv fcnd un ir nesfrit de activiti nesemnificative?______________________________________________________________________________________________________________________________________________________________

2. Sentimente

Subliniai fiecare din sentimentele urmtoare care vi se potrivesc (pe care le resimii) adesea:

furios energic plin de speran mulumit

plictisit invidios relaxat stimulat

suprat vinovat gelos optimist

deprimat fericit nefericit tensionat

anxios conflictual trist altele

temtor plin de regrete fr odihn

panicat lipsit de speran singur

Listai principalele frici/ temeri ale dvs.:1.____________________________________________________________________________________2.____________________________________________________________________________________3.____________________________________________________________________________________4.____________________________________________________________________________________5.____________________________________________________________________________________Care sunt sentimentele pe care le ncercai cel mai des?________________________________________________

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Ce sentimente / emoii ai vrea s trii mai puin des?_________________________________________________

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Enumerai cteva din sentimentele/ emoiile pozitive pe care le-ai trit de curnd?______________________________________________________________________________________________________________________________________________________________________________________________________

Cnd suntei cel mai adesea pe cale s v pierdei controlul asupra sentimentelor/ emoiilor dvs.?________________________________________________________________________________________Descriei o situaie semnificativ pentru acest lucru ___________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________Descriei situaiile care v fac s v simii calm, relaxat _______________________________________________

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_____________________________________________________________________________________________________________________________________________________________________V rugm s completai:

Dac v-a spune ce simt acum ______________________________________________________________________

Unul din lucrurile de care m simt mndru este ________________________________________________________

Unul din lucrurile de care m simt vinovat este ________________________________________________________

Sunt cel mai fericit cnd ___________________________________________________________________________

Unul din lucrurile care m supr cel mai tare este _____________________________________________________

Dac nu mi-ar fi team s fiu eu nsumi, a putea s ____________________________________________________

Dac m supr pe tine ____________________________________________________________________________

Ce fel de lucruri recreative sau hobby-uri v fac plcere, v relaxeaz? _________________________________

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Avei dificulti s v relaxai/ odihnii/ distrai n weekend-uri i vacane?_________________________________ Dac da, v rugm s explicai ___________________________________________________________________

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3. Senzaii fizice

Subliniai senzaiile pe care le resimii adesea:

Dureri de cap deranj stomacal probleme de piele

Ameeal ticuri gura uscat

Palpitaii oboseal mncrimi sau arsuri de piele

Spasme musculare contracii musculare dureri de piept

Tensiune dureri de spate bti rapide de inim

Tulburri sexuale tremurturi neplcerea de a fi atins

Incapacitate de relaxare momente de lein/slbiciune

Tulburri intestinale zgomote auzite transpiraie excesiv

Furnicturi ochi apoi tulburri de vedere

iuituri n urechi probleme de auz amoreal

4. Imagini

Subliniai fiecare din elementele care v caracterizeaz:

Imagini sexuale plcute imagini sexuale neplcute

Imagini de neajutorare imagini de singurtate imagini de a fi iubit

Imagini agresive imagini de seducie

Verificai care din urmtoarele vi se potrivesc:

M vd pe mine nsumi (m imaginez) ca:

Fiind lovit fiind brfit fiind ridiculizat

Neputnd s fac fa lovind pe alii fcnd promisiuni

Avnd succes fiind responsabil altele________________________________________

Pierzndu-mi controlul eund ____________________________________________Fiind urmrit fiind prins n curs _____________________________________________Ce imagine v vine n minte cel mai des? ________________________________________________________________________________________________________________________________________________________

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Descriei o imagine, un tablou mental sau o fantezie foarte plcut ____________________________________

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Descriei o imagine, un tablou mental sau o fantezie foarte neplcut ________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Descriei imaginea dvs. despre un loc complet sigur _________________________________________________ _______________________________________________________________________________________________

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5. Gnduri

Subliniai fiecare din urmtoarele gnduri care vi se potrivesc:

- Sunt lipsit de valoare, un nimeni, inutil i/ sau nedemn de a fi iubit

- Sunt neatrgtor, incompetent, stupid i/ sau indezirabil

- Sunt ru, nebun, degenerat i/ sau deviant

- Viaa este goal, un pustiu, nu este nimic spre care s caui s te ndrepi (n viitor)

- Fac prea multe greeli, nu fac nimic corect, bineSubliniai fiecare din urmtoarele cuvinte pe care le-ai putea utiliza pentru a v descrie:

Inteligent degenerat incompetent

ncreztor moral cu gnduri oribile

Meritoriu (valoros) atent conflictual

Ambiios un deviant cu dificulti de concentrare

Sensibil neatrgtor cu probleme de memorie

Loial nedemn de a fi iubit atrgtor

De ncredere inadecvat nu pot lua decizii

Plin de regrete confuz cu idei suicidare

Lipsit de valoare urt perseverent

Un nimeni prost ncpnat

Inutil stupid bun sim al umorului

Ru naiv muncitor

Nebun onest

Care considerai c este cel mai iraional gnd (idei pe care le avei)? ________________________________________

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Suntei deranjat de gnduri care revin mereu? _______________________________________________________

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Pentru fiecare din itemii urmtori, v rugm ncercuii numrul care reflect cel mai fidel opiniile dvs.:

1.dezacord puternic 2.dezacord 3. neutru 4. acord 5. acord puternic

a) Ar trebui s nu fac greeli a) 1. 2. 3. 4. 5.

b) Trebuie s fiu bun n tot ce fac b) 1. 2. 3. 4. 5.

c) Cnd nu tiu, ar trebui s pretind c tiu c) 1. 2. 3. 4. 5.

d) Ar trebui s nu dezvlui informaii personale d) 1. 2. 3. 4. 5.

e) Sunt o victim a circumstanelor e) 1. 2. 3. 4. 5.

f) Viaa mea este controlat de fore exterioare f) 1. 2. 3. 4. 5.

g) Ali oameni sunt mai fericii dect mine g) 1. 2. 3. 4. 5.

h) Este foarte important s-i mulumeti pe ceilali h) 1. 2. 3. 4. 5.

i) Joac singur; nu-i asuma nici un fel de riscuri i) 1. 2. 3. 4. 5.

j) Nu merit s fiu fericit j) 1. 2. 3. 4. 5.

k) Dac mi ignor problemele, ele vor disprea k) 1. 2. 3. 4. 5.

l) Este responsabilitatea mea s-i fac pe ceilali oameni fericii l) 1. 2. 3. 4. 5.

m) Trebuie s tind/ s m strduiesc spre perfeciune m) 1. 2. 3. 4. 5.

n) La baz sunt dou moduri de a face lucrurile : modul bun n) 1. 2. 3. 4. 5.

corect i modul prost, greitV rugm s completai urmtoarele:

Sunt o persoan care _____________________________________________________________________________

Toat viaa mea _________________________________________________________________________________

nc de cnd eram copil ___________________________________________________________________________

Este greu pentru mine s admit _____________________________________________________________________

Unul din lucrurile pe care nu le pot ierta este __________________________________________________________

Cnd i faci probleme ____________________________________________________________________________

Lucrul ru cnd creti mare este ____________________________________________________________________

Unul din modurile n care a putea s m ajut , dar nu o fac este __________________________________________

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6. Relaiile interpersonaleA. Familia de origine

Dac nu ai fost crescut de prini, cine v-a crescut i ntre ce ani?____________________________________________________________________________________________________________________________Dai o descriere a personalitii tatlui (sau a substitutului tatlui) i a atitudinii lui (prezente i trecute) fa de dvs. ___________________________________________________________________________________

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Dai o descriere a personalitii mamei (sau a substitutei mamei) i a atitudinii ei (prezente i trecute) fa de dvs. ______________________________________________________________________________________

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n ce moduri ai fost disciplinat ( pedepsit) de prini cnd erai copil?_________________________________________________________________________________________________________________________

_________________________________________________________________________________________Relatai o impresie asupra atmosferei casei dvs. (casa n care ai crescut). Menionai starea de compatibilitate dintre prini i dintre prini i copii. __________________________________________________________

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Puteai s avei ncredere/ s v confesai prinilor dvs.? ___________________________________________________________________________________________________________________________________V nelegeau prinii dvs.? __________________________________________________________________

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n fond, v-ai simit iubit i respectat de prini? ___________________________________________________________________________________________________________________________________________Dac avei un printe vitreg, precizai vrsta la care printele s-a recstorit___________________________S-a amestecat vreodat cineva (prini, rude, prieteni) n mariajul sau munca dvs., etc.? ____________________________________________________________________________________________________________________________________________________________________________________________________Care sunt cei mai apropiai oameni din viaa dvs.? ________________________________________________

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B. Prietenii

1. V facei prietenii cu uurin______________________________________________________________

2. i pstrai?____________________________________________________________________________

3. Ai fost vreodat terorizat sau ironizat dur?__________________________________________________

4. Descriei o relaie care v ofer:

Bucurie _______________________________________________________________________________

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Suprare ______________________________________________________________________________

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5. Notai msura n care v simii n general confortabil i relaxat n situaiile sociale (ncercuii):Foarte relaxat relativ confortabil relativ inconfortabil foarte anxios6. n general, v exprimai sentimentele, opiniile sau dorinele ntr-un mod deschis i adecvat?__________________________________________________________________________________________________Descriei indivizii fa de care (sau ntrebrile n care) avei dificulti s fii asertivi._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Avei unul sau mai muli prieteni cu care s v simii confortabil, s v mprtii cele mai intime gnduri sau sentimente? ___________________________________________________________________________

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C. Mariaja. De ct timp v cunoteai soia/ soul nainte de a v logodi?

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b. Ct timp ai fost cstorit? _______________________________________________________________c. De ct timp suntei cstorit? ____________________________________________________________

d. Care este vrsta soiei/ soului dvs.? _______________________________________________________

e. Care este ocupaia soiei/ soului dvs.?_____________________________________________________

f. Descriei personalitatea soiei/ soului dvs. __________________________________________________

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g. n ce arii suntei compatibili? ____________________________________________________________

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h. n ce arii suntei incompatibili? ___________________________________________________________

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i. Cum v nelegei cu rudele dvs. prin alian (socrii, cumnai etc)? ________________________________

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_________________________________________________________________________________________j. Ci copii avei? ____________Numele lor: _________________________________________________

_____________________________Vrsta ______________________________________________________

k. Prezint vreunul dintre ei probleme speciale? ________________________________________________

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D. Relaii sexualeDescriei atitudinea prinilor dvs. fa de sex. Se discuta despre sex acas?

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Cnd i unde ai obinut primele informaii despre sex?

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Cnd ai devenit prima dat contient de propriile impulsuri sexuale?

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Ai trit vreodat sentimente de anxietate sau vinovie provocate de sex sau masturbare? Dac da, v rugm s explicai_______________________________________________________________________

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Detalii relevante privind prime experien sexual sau cele ulterioare____________________________________________________________________________________________________________________

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Viaa dvs. sexual prezent este satisfctoare? Dac nu, v rugm explicai

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Oferii informaii despre orice reacie sau relaie homosexual

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V rugm notai orice problem/ preocupare sexual nediscutat mai sus

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______________________________________________________________________________________ E. Alte relaiia. Sunt probleme n relaiile cu oamenii la serviciu? Dac da, v rugm descriei

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b. V rugm completai urmtoarele:

i. unul din modurile n care oamenii m rnesc este____________________________________________________________________________________________________________________________________ii. a putea s ochez prin___________________________________________________________________

iii. o mam ar trebui _______________________________________________________________________

iv. un tat ar trebui ________________________________________________________________________

v. un prieten adevrat ar trebui ______________________________________________________________

c. Dai o scurt descriere a dvs. aa cum ai fi descris de:

a) soia/ soul dvs._______________________________________________________________________

b) cel mai bun prieten ____________________________________________________________________

c) cineva care v agreaz _________________________________________________________________

d) cineva care nu v agreaz ______________________________________________________________

d. Suntei n mod obinuit afectat de faptul de a fi respins n trecut sau de pierderea unei relaii de prietenie/ colegialitate? Dac da, v rugm explicai___________________________________________

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e. Suntei n mod obinuit afectat de faptul de a fi respins n trecut sau de pierderea unei relaii de dragoste? Dac da, v rugm explicai_______________________________________________________

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______________________________________________________________________________________7. Factorii biologici Verificai (ncercuii) care din urmtoarele v caracterizeaz (vi se potrivesc):

Avei preocupri curente legate de sntatea dvs. fizic? V rugm explicai ______________________________________________________________________________________

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V rugm enumerai medicamentele pe care le luai n mod curent sau pe care le-ai luat n ultimele 6 luni (inclusiv aspirin, pilule anticoncepionale sau medicamente prescrise sau autoadministrate)

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Avei n fiecare zi trei mese echilibrate? _____________________________________________________

Dac nu, v rugm explicai _______________________________________________________________

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Facei n mod regulat exerciii fizice? Dac da, ce tip i ct de des?

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Subliniai oricare din elementele urmtoare care vi se potrivete dumneavoastr:

Marijuana stimulante insomnie

Tranchilizante halucinogene (LSD,etc.) dureri de cap

Sedative diaree dureri de spate

Aspirin constipaie treziri timpurii dimineaa

Cocain alergii somn sntos(potrivit)

Analgezice pusee de tensiune mncat excesiv

Alcool probleme cardiace apetit srac

Cafea greuri mese de proast calitate

igri vom

Subliniai oricare din urmtoarele care se aplic membrilor familiei dvs.: boli tiroidiene, boli de rinichi, astm, boli neurologice, boli infecioase, diabet, cancer, boli gastrointestinale, probleme de prostst, glaucom, epilepsie, altele __________________________________________________________________________________________________________

_______________________________________________________________________________Ai avut vreodat boli ale corpului sau pierderi de contiin? V rugm dai detalii

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______________________________________________________________________________________V rugm descriei orice operaie chirurgical pe care ai avut-o (dai date)

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Descriei orice fel de accidente sau traumatisme de care ai suferit (dai date)

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______________________________________________________________________________________ 8. Istoria etapelor

V rugm subliniai (scriei) cele mai semnificative amintiri sau experiene de via corespunztoare urmtoarelor etape de vrst:

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11-15 _________________________________________________________________________________________

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16-20 _________________________________________________________________________________________

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21-25 _________________________________________________________________________________________

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51-55 _________________________________________________________________________________________