Plano Individual

de Atendimento
PIA

I - DADOS PESSOAIS
AUTOS: ________________________________________________________________________________________________
NOME: ________________________________________________________________________________________________
DATA DE NASCIMENTO: ______/______/_________

SEXO: [ ] FEMININO

[ ] MASCULINO

NACIONALIDADE: ________________________________ NATURALIDADE: ________________________________________

FILIAO

ME:________________________________________________________________________________________
Endereo/telefone: __________________________________________________________________________

FILIAO

PAI:_________________________________________________________________________________________
Endereo/telefone:_____________________________________________________________________________

RESPONSVEL: __________________________________________________________________________________________
LTIMO ENDEREO DO ACOLHIDO: _________________________________________________________________________
CIDADE/UF :________________________________________________________CONTATO____________________________
N CERTIDO DE NASCIMENTO: _________________________________ FOLHA: ___________ LIVRO:__________________
CARTRIO:_____________________________________________________________________________________________
CPF: _____________________ RG: ____________________DATA EMISSO: _____/____/______ORG. EMISSOR: _________
CTPS: __________________________________ SRIE: ________________ PIS _____________________________________
TTULO DE ELEITOR: _____________________________________________________________________________________
OBSERVAES:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

II - DADOS DO ACOLHIMENTO
1 - AUTOS:______________________________________________________________________________________________
2 - DATA DO ACOLHIMENTO:______/_____/_____

3. N DA GUIA DE ACOLHIMENTO: ____________________________

4. ENCAMINHADO POR: ___________________________________________________________________________________

_______________________________________________________________________________________________________
5. MOTIVO DO ACOLHIMENTO CONFORME O RGO ENCAMINHADOR (identificar quem violou o direito):
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
____________________________________________________________________________
6. DOCUMENTAO RECEBIDA:

DATA DE RECEBIMENTO:

] GUIA DE ACOLHIMENTO

_______ / _______ / _________

] CERTIDO DE NASCIMENTO (ORIGINAL)

_______ / _______ / _________

] CARTEIRA DE VACINAO

_______ / _______ / _________

] CARTO DO SUS

_______ / _______ / _________

] BOLETIM DE OCORRNCIA

_______ / _______ / _________

] CARTEIRA DE IDENTIDADE

_______ / _______ / _________

] CPF

_______ / _______ / _________

] RELATRIO DO CONSELHO TUTELAR

_______ / _______ / _________

] RELATRIO DE PROGRAMA DE ATENDIMENTO SCIO-FAMILIAR

_______ / _______ / _________

] LAUDO DO IML

_______ / _______ / _________

] OUTROS: ___________________________________________________

_______ / _______ / _________

___________________________________________________

_______ / _______ / __________

7 - CONDIES EM QUE OCORREU A RETIRADA DA CRIANA/ADOLESCENTE DA FAMLIA (local, como foi a abor

dagem, reaes da criana/adolescente e dos familiares):

______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
8 - CONDIES DA CRIANA/ADOLESCENTE NO MOMENTO DO ACOLHIMENTO:
8.1 HIGIENE ____________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
8.2 REAES E COMPORTAMENTOS: __________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
8.3 SINAIS DE VIOLNCIA:__________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

9. ACOLHIMENTO ANTERIOR:
9.1 INSTITUIO ________________________________________________________________________________________
DATA DA ENTRADA: _____ /_______ /_________

DATA DA SADA: _____ /_______ /_________

9.2 MOTIVO DO ACOLHIMENTO ANTERIOR:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

9.3 MOTIVO DO DESACOLHIMENTO ANTERIOR:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

10. ENCAMINHAMENTOS DADOS FAMLIA E CRIANA / ADOLESCENTE ANTERIORMENTE AO ACOLHIMENTO INSTITUCIONAL:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

OBSERVAES:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

III FAMLIA
1. DADOS DA FAMLIA
1.1 ARRANJO FAMILIAR (pessoas que residiam com a criana/adolescente)
IDADE

NOME

PARENTESCO

PROFISSO/OCUPAO

RELIGIO

ESCOLARIDADE

CONTATO

1.2 FAMLIA EXTENSA/AMPLIADA (que no reside no domiclio, mas possui vnculos)

IDADE

NOME

PARENTESCO

PROFISSO/OCUPAO

RELIGIO

ESCOLARIDADE

CONTATO

RELIGIO

ESCOLARIDADE

CONTATO

1.3 H INTERESSADOS NA GUARDA DA CRIANA/ADOLESCENTE?

IDADE

NOME

PARENTESCO

PROFISSO/OCUPAO

1.4 A FAMLIA ATENDIDA POR PROGRAMA/BENEFCIO SOCIAL?

[

] SIM

] NO

QUAL PROGRAMA?

QUEM?

] PROGRAMA DE TRANSFERNCIA DE RENDA

______________________

__________________________________________

]] PROGRAMA DE ATENDIMENTO FAMLIA

______________________

__________________________________________

]] BENEFCIO DE PRESTAO CONTINUADA

______________________

__________________________________________

]] BENEFCIOS PREVIDENCIRIOS

______________________

__________________________________________

]] PROGRAMA DE HABITAO

______________________

__________________________________________

]] OUTROS: ________________________________

______________________

__________________________________________

1.5 COMPOSIO DA RENDA FAMILIAR:

FAMILIARES POSSUEM RENDA PROVENIENTE DE ATIVIDADE LABORAL E/OU PENSO ALIMENTCIA?
( ) SIM ( ) NO - INFORME ABAIXO QUEM:

VALOR QUE RECEBE POR

MS

RELAO COM O TRABALHO

(formal, informal, autnomo, etc)

1.6 CONDIES DE MORADIA

[

] ALUGADA

] PRPRIA

] OUTROS

] CEDIDA

1.7 INFRAESTRUTURA
[

] GUA

] ENERGIA ELTRICA

] COLETA DE LIXO

] ESGOTO

] OUTROS

1.8 CONDIES DE HABITABILIDADE (HIGIENE, ORGANIZAO, PRIVACIDADE)

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
1.9 INFRAESTRUTURA DA COMUNIDADE
[

] UNIDADE DE SADE

] CRECHE

] ESCOLA

] PROJETO DE CONTRATURNO

] OUTROS

1.10 A FAMLIA ATENDIDA PELOS SERVIOS DE SADE?

[

] SIM

] NO

LOCAL?

QUEM?

] PROGRAMA DE SADE DA FAMLIA - ATENO BSICA

__________________ __________________

] CAPS

__________________ __________________

] CAPS - AD

__________________ __________________

] CAPSI

__________________ __________________

] DE LCOOL E/OU DROGAS

__________________ __________________

] OUTROS: ___________________________________________

__________________ __________________

OBSERVAES:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

2 - RELAES FAMILIARES
2.1 COMO A RELAO COM A FAMLIA (fugas de casa, vnculos afetivos, indiferenas, brigas, etc):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2.2 PERCEPO DA FAMLIA SOBRE A CRIANA/ADOLESCENTE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2.3 PERCEPO DA CRIANA/ADOLESCENTE SOBRE A FAMLIA:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2.4 PERCEPO DA EQUIPE TCNICA SOBRE AS RELAES FAMILIARES:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2. 5 A CRIANA RECEBE VISITAS?
[

] SIM

] NO

QUEM?

COM QUE FREQUNCIA?

SE NO, QUAL(IS) O(S) MOTIVO(S)?

____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. 6 COMPORTAMENTOS DA CRIANA / ADOLESCENTE DURANTE A VISITA:
_______________________________________________________________________________________________________

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2.7 COMPORTAMENTOS DOS FAMILIARES DURANTE A VISITA:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________
2. 8 A CRIANA TEM
IRMO:

NOME DOS IRMOS

] SIM [

] NO

IDADE

2.8.1 - NOS CASOS DE GRUPOS DE IRMOS ACOLHIDOS, H

VISITAS?

LOCAL

] SIM

] NO

COM QUE FREQUNCIA E DURAO?

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
SE NO, QUAL(IS) O(S) MOTIVO(S)?

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
OBSERVAES:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

3. RELAO COM A COMUNIDADE

3. 1 RELATAR SOBRE OS VNCULOS DE AMIZADE E NAMORO: (quais os amigos, onde residem, se j nomorou):

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. 2 RELAO COM A COMUNIDADE: (como a relao, participa de atividades, possui rivalidade, pessoas de referncia):

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3.3 RELAO COM A INSTITUIO: (relacionamento com a equipe, o que bom, o que ruim, pessoas de referncia):

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
OBSERVAES:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

IV EDUCAO
1. FREQUENTAVA A ESCOLA ANTES DO ACOLHIMENTO? [

] SIM

NO

1.1 NOME:_______________________________________________________________________________________________
1.2 ENDEREO:___________________________________________________________ BAIRRO: _______________________
CIDADE: ______________________________________________________________ _ TELEFONE: (

) ________________

1.3 SE NO, POR QUAL MOTIVO?

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. ESCOLA APS O ACOLHIMENTO:

DATA DE MATRCULA

___________________________________________________________________
SRIE/ANO E TURMA: ________________________________________________

______/______/________
TURNO: ____________________________

2.1 ENDEREO: _____________________________________________________ TELEFONE: (

__________________________________________________________________

)_____________________
BAIRRO ____________________________

CIDADE:

CEP:

_________________________________________________________

______________________________

3. COORDENADOR OU ORIENTADOR PEDAGGICO:

_______________________________________________________________________________________________________
4. APRESENTA NECESSIDADES E DIFICULDADES NA APRENDIZAGEM? Especificar:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. FREQUENTA ATIVIDADES DE APOIO PEDAGGICO? Especificar:
_______________________________________________________________________________________________________

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
6. FREQUENTA ATIVIDADES DE CONTRATURNO ESCOLAR:

QUAIS?

] SIM

ONDE?

] NO

7. COMO O COMPORTAMENTO NA ESCOLA?

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
8. COMO PERCEBE A ESCOLA E AS RELAES ESTABELECIDADES NESTE ESPAO? (do ponto de vista do aluno):

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
9. QUAIS AS PERSPECTIVAS/OBJETIVOS QUANTO AOS ESTUDOS?

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
OBSERVAES: (encaminhamentos da escola e outros):

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

V SADE
1. PESO: ____________ 2.ALTURA: ______________ 3. TIPO SANGUINIO: __________________ 4. FATOR RH __________
5. TOMOU AS VACINAS NECESSRIAS CONFORME A IDADE?

] SIM

] NO

ESPECIFIQUE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
6. APRESENTA ALGUM PROBLEMA DE SADE?

] SIM

] NO

ESPECIFIQUE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
7 . EST REALIZANDO ALGUM TRATAMENTO?

] SIM

] NO

ESPECIFIQUE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
8. FAZ USO DE MEDICAMENTO?

] SIM

] NO

ESPECIFIQUE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
9. POSSUI ALGUMA ALERGIA?

] SIM

] NO

ESPECIFIQUE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
10. REALIZOU ALGUMA CIRURGIA?

] SIM

ESPECIFIQUE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

] NO

11. TEM ALGUMA DOENA CRNICA?

] SIM

] NO

ESPECIFIQUE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
12. ALGUM DA FAMLIA TEM DOENA CRNICA?

] SIM

] NO

ESPECIFIQUE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
13. REALIZA ACOMPANHAMENTO PSICOLGICO?

] SIM

] NO

ESPECIFIQUE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
14. REALIZA ACOMPANHAMENTO PSIQUITRICO/NEUROLGICO?

] SIM

] NO

] NO

ESPECIFIQUE:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
15. POSSUI ALGUM TIPO DE DEFICINCIA?

] SIM

ESPECIFIQUE:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
ENCAMINHAMENTOS:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

16. FEZ OU FAZ USO DE LCOOL/DROGAS?

] SIM

] NO

ESPECIFIQUE:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
17. USO DE LCOOL/DROGA NA FAMLIA?
ESPECIFIQUE:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
18. NO LTIMO ANO TEVE NECESSIDADE DE RECORRER A ALGUM SERVIO DE SADE, ODONTOLGICO OU MDICO?
[

] SIM

] NO

ASSINALE MOTIVO:
[ ] CONSULTA DE ROTINA

] CONSULTA DE EMERGNCIA

] OUTROS

ENCAMINHAMENTOS:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

VI DESENVOLVIMENTO
1. ALIMENTAO:
1.1 APRESENTA BOM APETITE?

] SIM

]NO

1.2 APRESENTA ALERGIA A ALIMENTOS?

] SIM

]NO

ESPECIFIQUE:____________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

1.3 Recusa alimentos?

] SIM

] NO

1.4 Necessita ajuda para alimentao?

] SIM

] NO

Especifique:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

2. SONO:
2.1 APRESENTA ALTERAES DE SONO?

] SIM

] NO

Especifique:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3. LINGUAGEM
Apresenta vocalizao compatvel com a faixa etria?

] SIM

] NO

Apresenta dificuldades na pronncia das palavras?

] SIM

] NO

Compreende perguntas que lhe so feitas?

] SIM

] NO

Apresenta gagueira?

] SIM

] NO

] NO

] NO

ESPECIFIQUE:___________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

4. PSICOMOTROCIDADE
4.1 Apresenta dificuldade para movimentar-se?

] SIM

ESPECIFIQUE: ___________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4.2 Reage a estmulos auditivos?

] SIM

ESPECIFIQUE: ___________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

4.3 Reage a estmulos visuais?

] SIM

] NO

] SIM

] NO

] SIM

] NO

ESPECIFICAR: ___________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4.4 Apresenta dificuldades na coordenao motora?

ESPECIFICAR: ___________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

5. SINTOMAS PSICOFISIOLGICOS
5.1Apresenta dificuldades para controle de esfncteres?

ESPECIFICAR: ___________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

5.2 Ri unhas?
5.3 Chupa dedo?
5.4 Apresenta dificuldades na coordenao motora?

] SIM

] NO

] SIM

] NO

] SIM

] NO

ESPECIFCAR: ___________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

6. SOCIALIZAO
6.1 Diferencia pessoas conhecidas de pessoas estranhas?
6.2 Demonstra interesse em interagir com adultos?
6.3 Demonstra interesse em interagir com outras crianas?

] SIM

] NO

] SIM

] NO

] SIM

] NO

] NO

ESPECIFCAR: ___________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

7. SEXUALIDADE:
7.1 Apresenta comportamento relativo a sexualidade compatvel com a faixa etria?

] SIM

ESPECIFCAR: ___________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
OBSERVAES:__________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

VII - PROFISSIONALIZAO
1. J DESENVOLVEU ALGUMA ATIVIDADE REMUNERADA?

] SIM

QUAL
____________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2. QUAL(is) DELA(s) SE IDENTIFICOU? QUAL(is) REPETIRIA?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
3. POSSUI ALGUMA HABILIDADE/TALENTO?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4. QUAL A SUA PERCEPO DO TRABALHO?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
5. QUAL(is) CURSO(s) PROFISSIONALIZANTE(s) J FEZ? QUAL(is) GOSTARIA DE FAZER?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
6. COM QUAL(is) PROFISSO(es) SE IDENTIFICA? O QUE GOSTARIA DE APRENDER?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
OBSERVAES: __________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

] NO

VII - ESPORTE, CULTURA E LAZER

1. QUAIS AS ATIVIDADES COM QUE SE IDENTIFICA E/OU PRATICA?
1.1. ESPORTIVAS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

1.2. CULTURAIS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

1.3 LAZER:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

PLANO DE AO COM A CRIANA/ADOLESCENTE (P.A.C.A.)

1 opo de modelo

AUTOS:
NOME DA CRIANA/ADOLESCENTE:
INSTITUIO DE ACOLHIMENTO:
FAMLIA ACOLHEDORA:
1. CARACTERIZAR A AVALIAO PRELIMINAR SOBRE AS NECESSIDADES IDENTIFICADAS EM
RELAO A
CRIANA/ADOLESCENTE (devem ser observadas as reas da convivncia familiar e comunitria;
sade; educao; desenvolvimento; assistncia social; habitao; profissionalizao;
socializao, esporte, cultura e lazer; documentao, entre outras):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

2. CARACTERIZAR OS ENCAMINHAMENTOS, AS AES PRELIMINARES, BEM COMO O TCNICO RESPONSVEL

EO
PRAZO, ACERCA DAS INTERVENES PARA SUPERAO DAS NECESSIDADES IDENTIFICADAS EM
RELAO A
CRIANA/ADOLESCENTE (devem ser observadas as reas da convivncia familiar e comunitria;
sade; educao;
desenvolvimento; assistncia social; habitao; profissionalizao; socializao, esporte, cultura e
lazer; documentao, entre outras) :
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

3. PARECER EQUIPE TCNICA:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
PRAZO PARA REAVALIAO: _______________________________________________________________________________

____________________________________, ________/_______/_________.
(CIDADE)

ASSINATURA DOS TCNICOS RESPONSVEIS:

PLANO DE AO COM A CRIANA/ADOLESCENTE (P.A.C.A.)

2 opo de modelo

AUTOS:
NOME DA CRIANA/ADOLESCENTE:
INSTITUIO DE ACOLHIMENTO:
FAMLIA ACOLHEDORA:
REA

DEMANDA CONSTATADA
(DIFICULDADE)

ESTRATGIAS

ENCAMINHAMENTOS

PRAZO RESPONSVE
L

DEMANDA CONSTATADA
(POTENCIALIDADES)

ESTRATGIAS

ENCAMINHAMENTOS

PRAZO RESPONSVE
L

SADE
EDUCAO
ASSISTNCIA SOCIAL
HABITAO
PROFISSIONALIZAO
TRABALHO
SOCIALIZAO, ESPORTE,
CULTURA E LAZER
CONVIVNCIA FAMILIAR E
COMUNITRIA

DOCUMENTAO
OUTROS

REA
SADE
EDUCAO
PROFISSIONALIZAO
TRABALHO
SOCIALIZAO, ESPORTE,
CULTURA E LAZER
CONVIVNCIA FAMILIAR E
COMUNITRIA

OUTROS

PARECER DA EQUIPE TCNICA:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

PRAZO PARA REAVALIAO: _____________________________________________________________

________________________________, ________/_______/_________.
(CIDADE)

ASSINATURA DOS TCNICOS RESPONSVEIS:

PLANO DE AO COM A FAMLIA (P.A.F)

1 opo de modelo

AUTOS:
NOME DA CRIANA/ADOLESCENTE:

INSTITUIO DE ACOLHIMENTO:
FAMLIA ACOLHEDORA:
1. CARACTERIZAR A AVALIAO PRELIMINAR SOBRE AS NECESSIDADES IDENTIFICADAS EM RELAO A FAMLIA DA
CRIANA/ADOLESCENTE (devem ser observadas as reas da convivncia familiar e comunitria; sade; educao;
desenvolvimento;

assistncia

social; habitao;

profissionalizao;

socializao,

esporte,

cultura

e lazer;

documentao, entre outras):

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

2. CARACTERIZAR OS ENCAMINHAMENTOS, AS AES PRELIMINARES, BEM COMO O TCNICO RESPONSVEL E O

PRAZO, ACERCA DAS INTERVENES PARA SUPERAO DAS NECESSIDADES IDENTIFICADAS EM RELAO A FAMLIA
DA CRIANA/ADOLESCENTE (devem ser observadas as reas da convivncia familiar e comunitria; sade; educao;
desenvolvimento; assistncia social; habitao; profissionalizao; socializao, esporte, cultura e
lazer; documentao, entre outras) :
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

3. CARACTERIZAR A PARTICIPAO E COMPROMISSOS ASSUMIDOS PELA FAMLIA EM RELAO A ESTE PLANO:

(sugesto anexar o termo de compromisso assinado pelos familiares)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

4. PARECER EQUIPE TCNICA:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

PRAZO PARA REAVALIAO: _______________________________________________________________________________

____________________________________, ________/_______/_________.
(CIDADE)

ASSINATURA DOS TCNICOS RESPONSVEIS:

Plano Individual
de Atendimento - PIA
REAVALIAO I
AUTOS: ______________________________________________________________________________________
DATA DE APRESENTAO DO PIA: _______/_______/__________
DATA DE APRESENTAO DO PIA REAVALIAO I: _______/_______/__________

I - DADOS ATUAIS DA CRIANA

NOME:

____________________________________________________________________________________

DATA DE NASCIMENTO:

SEXO:

_______ /_________ /_______________

] FEMININO

] MASCULINO

ESCOLARIDADE: _______________________________________________________________________________
DOCUMENTAO ATUAL: ________________________________________________________________________
_____________________________________________________________________________________________
ENTIDADE DE ACOLHIMENTO: ___________________________________________________________________
DATA DO ACOLHIMENTO NA INSTITUIO: _______ /_______ /__________

1. FORAM IDENTIFICADOS OUTROS ELEMENTOS QUE CARACTERIZARAM A SITUAO DE RISCO DA

CRIANA/ADOLESCENTE EM RELAO AO MOTIVO DO ACOLHIMENTO:
[

] SIM

] NO

ESPECIFIQUE: _________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

2. A CRIANA/ADOLESCENTE RECEBE VISITAS?

QUEM?

] SIM

] NO

COM QUE FREQUNCIA?

SE NO, QUAL(IS) O(S) MOTIVO(S)?

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

3. COMPORTAMENTOS DA CRIANA/ADOLESCENTE DURANTE A VISITA:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

4. COMPORTAMENTOS DOS FAMILIARES DURANTE A VISITA:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

5. CARACTERIZAR AS ESTRATGIAS J REALIZADAS PARA O ATENDIMENTO DAS

NECESSIDADES DA
CRIANA/ADOLESCENTE, AS DIFICULDADES ENCONTRADAS E OS RESULTADOS OBTIDOS: (devem ser
observadas
as reas da convivncia familiar e comunitria; sade; educao; desenvolvimento;
assistncia social; habitao; profissionalizao; socializao, esporte, cultura e lazer;
documentao, entre outras):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

6. A CRIANA PARTICIPA DE ATIVIDADE COM VOLUNTRIOS E/0U PROGRAMA DE APADRINHAEMNTO AFETIVO?

[

] SIM

] NO

SE SIM, ESPECIFICAR AS ATIVIDADES REALIZADAS, COM QUEM E A FREQUNCIA:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

II - DADOS ATUAIS DA FAMLIA: (obrigatoriamente incluir pais e outras pessoas interessadas na guarda)
NOME

PARENTESCO

ENDEREO

TELEFONE

INTESSE NA
GUARDA

1. CARACTERIZAR AS CONDIES DE RENDA, HABITABILIADADE E INFRAESTRUTURA DA FAMLIA:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

2. A FAMLIA EST RECEBENDO ACOMPANHAMENTO E ORIENTAO? QUAL INSTITUIO E/OU SERVIO

RESPONSVEL PELO ACOMPANHAMENTO? QUAIS OS OBJETIVOS DO ACOMPANHAMENTO?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

3. CARACTERIZAR O PROJETO DE VIDA DA FAMLIA

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

4. CARACTERIZAR A SITUAO SCIO-FAMILIAR, OS PROBLEMAS E AS NECESSIDADES DE MUDANA DA FAMLIA

PARA O RETORNO DA CRIANA/ADOLESCENTE AO CONVVIO FAMILIAR:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

5.CARACTERIZAR AS ESTRATGIAS J REALIZADAS PARA O RETORNO DA CRIANA/ADOLESCENTE AO CONVVIO

FAMILIAR, AS DIFICULDADES ENCONTRADAS E OS RESULTADOS OBTIDOS: (devem ser observadas as reas
da convivncia familiar e comunitria; sade; educao; assistnciasocial; habitao; profissalizao;
socializao, esporte, cultura e lazer; documentao, entre outras):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

6. QUAL O INTERESSE MANIFESTADO E COMPROMISSOS ASSUMIDOS PELA FAMLIA CRIANA/ADOLESCENTE AO

CONVVIO FAMILIAR?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

7. NO MOMENTO ATUAL, H POSSIBILIDADE DE RETORNO DA CRIANA/ADOLESCENTE AO CONVVIO FAMILIAR?

ESPECIFIQUE:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

8. A PARTIR DO MOMENTO ATUAL, CARACTERIZAR AS NECESSIDADES IDENTIFICADAS E ESTRATGIAS A SEREM

REALIZADAS PARA O RETORNO DA CRIANA/ADOLESCENTE AO CONVVIO FAMILIAR, BEM COMO O TCNICO
RESPONSVEL E O PRAZO: (devem ser observadas as reas da convivncia familiar e comunitria;
sade; educao; assistncia social; habitao; profissionalizao; socializao, esporte, cultura e lazer;
documentao, entre outras):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

9. CARACTERIZAR A PARTICIPAO NA ELABORAO DO PIA E COMPROMISSOS ASSUMIDOS PELA

FAMLIA EM RELAO AOS ENCAMINHAMENTOS (sugesto anexar o termo de compromisso assinado
pelos familiares)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

10. NO CASO DE CRIANAS/ADOLESCENTES EM QUE NO H POSSIBILIDADES DE RETORNO AO CONVVIO DA

FAMLIA DE ORIGEM:
10.1 CARACTERIZAR AS ESTRATGIAS REALIZADAS PARA A PREPAO DA
CRIANA/ADOLESCENTE PARA O
DESLIGAMENTO POR COLOCAO EM FAMLIA SUBSTITUTA (intervenes psicolgicas,
aproximao gradativa, prazos):
MODALIDADE: GUARDA, ADOO NACIONAL, ADOO INTERNACIONAL
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

10.2 CARACTERIZAR AS ESTRATGIAS REALIZADAS PARA A PREPARAO DO ADOLESCENTE PARA O

DESLIGAMENTO POR MAIORIDADE: (abordar as condies emocionais, profissionalizao e insero no mercado de
trabalho, promoo de vnculos e formao de rede apoio para o adolescente, etc):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

11. PARECER EQUIPE TCNICA:

__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

12. PRAZO PARA REAVALIAO: ___________________________________________________________________________

____________________________________, ________/_______/_________.
(CIDADE)

ASSINATURA DOS TCNICOS RESPONSVEIS:

PLANO DE AO COM A FAMLIA (P.A.F)

2 opo de modelo

AUTOS:
NOME DA CRIANA/ADOLESCENTE:
INSTITUIO DE ACOLHIMENTO:
FAMLIA ACOLHEDORA:

REA

CONVIVNCIA FAMILIAR E
COMUNITRIA (em relao ao
motivo do acolhimento)

SADE
EDUCAO
ASSISTNCIA SOCIAL
HABITAO
PROFISSIONALIZAO
TRABALHO
ESPORTE, CULTURA E LAZER
OUTROS

DEMANDA CONSTATADA
(DIFICULDADES)

DEMANDA CONSTATADA
(POTENCIALIDADES)

ESTRATGIAS

ENCAMINHAMENTOS

PRAZO

RESPONSVEL

PARECER DA EQUIPE TCNICA:

_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________

PRAZO PARA REAVALIAO:

_________/ _________/ ____________

________________________________, ________/_______/_________.
(CIDADE)

ASSINATURA DOS TCNICOS RESPONSVEIS: