Çocuk Ruh Sağlığı Dersi Bigi Formu

…………………..  ANAOKULU

KİŞİSEL BİLGİ FORMU

ÇOCUĞUN

Adı-Soyadı                            : ………………………….

Doğum Tarihi                         : ………………………….

Cinsiyeti                                 : ………………………….

Kabul Tarihi                           : ………………………….

Okula Geliş Nedeni               : ………………………….

Ev  Adresi ve Tel.                  : ………………………….

………………………………………………………………

………………………………………………………………

ANNE

Adı-Soyadı                            : ………………………….

Doğum Tarihi                         : ………………………….

Mesleği                                   : ………………………….

Çalışma Saatleri                     : ………………………….

Açık İş Adresi                                   : ………………………….

………………………………………………………………

Ev Adresi ve Tel

(Anne-baba ayrı ise)               : ………………………….

………………………………………………………………

Sağ  (   )                     Öz (   )                         Üvey (   )

                                                                    

BABA

Adı-Soyadı                            : ………………………….

Doğum Tarihi                         : ………………………….

Mesleği                                   : ………………………….

Çalışma Saatleri                     : ………………………….

Açık İş Adresi                                   : ………………………….

………………………………………………………………

Ev Adresi ve Tel

(Anne-baba ayrı ise)               : ………………………….

………………………………………………………………

Sağ (   )                     Öz (   )                      Üvey (   )

                                                                    

III. ŞAHIS

Adı-Soyadı                            : ………………………….

Yakınlık Derecesi                   : ………………………….

İş Adresi                                 : ………………………….

İş Telefonu                             : ………………………….

Ev Adresi                               : ………………………….

Ev Telefonu                            : ………………………….

Anne – Baba ayrı ise çocuk kiminle yaşıyor?

Anne (   )         Baba (   )      Anneanne (   )        Babaanne (   )          Diğer (   )

                                                                                                               

KARDEŞLER

            ADI                               DOĞUM TARİHİ                      EĞİTİM DURUMU

1- ……………………               ……./ ……./ …….                                     …………………

2- ……………………               ……./ ……./ …….                                    …………………

3- ……………………               ……./ ……./ …….                                   …………………

4- ……………………               ……./ ……./ …….                                     …………………

5- ……………………               ……./ ……./ …….                                    …………………

AİLEDE BİRLİKTE YAŞAYAN DİĞER KİŞİLER

          ADI                      YAKINLIK DERECESİ             YAŞI          EĞİTİM DURUMU

1- ………………..             ……………………               ……….        …………………………

2- ………………..             ..…………………..               ……….        …………………………