Ivc.ch.n,al"ime First

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REHABILI'IATION C3NT2R REPEKEAL PORM
Rehabilitations Center Einweioiingsformular
1 ii
R»C,No,
i a!
First
V6rnv.nie
Ivc.ch.n,al"ime
Bii^th Date
Geburt adatum"
Eirth Place
'Geburtsort *'
Lst Residence
Letzte Adreese
Emigration Status
Emigrationsstani *
Place of Issue
'Ausstell-'.ngsort
Referred bjr
Eingewieaen'dfin;;
Late
Datum
• Marital Status
'Personenatand
*
Identific.IFc,
Ausvveis -.Mo * " *
^
Pate of issue
AcisstellungsdatuiTi'
Date admitted tc Refeab,Center
2inweisungnda.tuin fiir Rehab
•.
GOCIy.L HiaVQRY
oor/iare" yinga"be"
Members of Famil5r:Faroilienraitglieder ;
Name
liame
__RelationsUi£_
Verv/andtschaf tagra3
.
^ ?r::y_^OUS EDUj:A':1PN.
~~
Age_
Alter"
_Addr'es2_
'Adresse'
r.i-.herige Schulun^:
r
Formal Schooling
Kaino of
Daten
Grr.de
lUTdungsanotalten
3c}iool
Atten^od_
Ooraplete_d_
IJame d"^clTule'l)aton"d*ey Sciiulgrad'
Iduuchs
erreicrt
Elementary School
Vclkgechule
]
_ ^
~ -
Ilig^tochool
L'ohcre Schiile
•>
''niversity
''niver^itat
•
•^rof essional_
"f'rufssclrale
£
~
i
hSi*i8iSi:9fa^E£_i
ilRf¥5rtj:Sgu.?i''i2i2e
IfgigfLn-:^!
,
:
1
Sub.iect
Fach
WORK EXPERIENCE
Beru'f serTaHrung ' '
Tvpe of Work
Art d,Arbeit
Dates Employed
Warm beschaftigt
. ^ "
Name Emplyer or Pirm
Hame d^Arbeit^ebers
Oder der Firma
<
Special Interpstg, .
Besondere Interessen
Skills _
Fahif^keiten'
Avocation
' Beruf
PI^PA^TIOK OF PATJSNT PP.IOR TO REFFm^Mj_:p :SE-I^PILITA?IOT CENTER
VorbereiTuhg des Patienton"vor Ueberv/oTsun^ an ileLabiTitationa CenterSpecify the nature of the preparation given,
by whom, and
recults. For example, if the- patient has taken educationcil coursea
or vocational training, or engaged in social recreational activities
list each ^^^pa^ately giving the above info3*nation and describe also
his adjustment to cach_and his final achieveicent.
Genauc '.ngaben betreffs der Art der Vorbcreitung, Iiaten, durch v/en
vorbsreitet und erzielte Resultate, Z«D» : V/enn.der Patient bildende
K»rse -il'cgcmacht oder Berufsaasbildung genoosen hat, odcr sdc.i in
aozialur rr^ir.eittatigkeit betiitigt hat» alles ist gesondert anzugoben
Obige Aiij::. c.-i aind erbeten unter gleichzeitiger Mitfeilung bctr..
Einsjcilun^: dca PatiCnten in jodem Falle und betr. endgUltigen Hesul tatcG-.
" "
•
1
•
• _SCR£:5I^ING IUTERVIEY;
j^TsrSSE "iiE'srREGHla^G"
w
G-ive brief sununar? o i interviews held but the follovv-ing information
must be included:
'' '
ICurzer liberblj-ck ubor die Ausspracne, inklusive folgcnder Information:
State patient'3 reai^ons for aocepting or rejecting Rehabilitation
SetvicG. Grlinde, weaUalb Pstiont Reliabilitation Center annimt Oder
ablehnt:
1
V/hat help did the interviewer civc in the discuasio-n^pf ProDlen£3?
Welcl'.c 'ilfc bot dor Int'.rviev/cr in der. I;er?prechung der Problorne?
Jhat were t: e rcGults of t);e Interview'
•V/as war uRc-Srgcbnia dor
Oouroe of trainin^^ requested ry patient:
V.'elcher ''reinin^kuro \.-urde voni Pation;yt.:n f^o./iinsCiit?
-
iutient'fl i-tato.'ncnt re "living apart ,fro.-^ family"
V.'i.," rc;-si^i'l Patient auf die Trennung von d-r yaniilie?
Patier. ' . own otatement of Iiit? vocational and other pl^.n3 for t}ie
—
Angabon doc Paticnten besgl. seiner b.^'ruflichcu
•" f
oonotigon Suku.if tnpliino:
Interviewer's evaluation oi' the patient, to include need of special
aitGntion or special conditions:
j^es Auclosenden lieGutachtung des Pationten inklusive ymgabon oetr,
gpesicller Teachtung und "besonderer Todingungon,:
PT:'R::TVISVRIK' S RECOI.::.IS:;DA}.'IO:IS
"Tn^;rvie\vcr's ErapfohTungon
Check
iiberpr-afe
-Patient Accoptod.
.Pat. ansono.iLu-n-
Patient _
^
_
""y^rsdhobcn
Reasons:
Griinda :
.'hat Preparation is Necoacr-ry?
'.'.'olche Voroercitung wird bcnotigt?
Opinion:' stated r.bout pationt
Meir.unf; bexr. d,Pationi,on;
a)Ts Pa':i
1st ucr
By:~
.Von:
Ir.tclligont?
inuglligcnl?
b) liac ho i:;ocd rclationt;hip to olhcr pailincs?
V/ic ist {?eiu Vcrlialtc-n zu ai.dcrcn Paticntcn?
o). Any difficulties in diaciplino?
•„
^
Irgcr.d v^elciic Echv.-icr ijicui vcn bczgl. Lii^ziplin?
d)
le iio intcrootc'.} in worlrin?
What is )iit'
Intcrerjsicrt ihn die. .\rbcit?
"Arbeit.gquujitu'.i'!"
jiours daily
'
t-gl.Stundt-nzahl?
t) Does ho need spccial atxontion?_
iluss man sich besondors niit'i:.:n IScscnaT
With regard to:
'^ctrcff;3
:
''
•_
/.
V/];y?
V/nru!((?~
^
Pinal Docision;
Endgultigc Entsciioiduiif^:
V/ill bo aclmii;o.;d to Kcl..-.b.Contcr at
Aufzunehmon i:a KCihali.Cunoor in :
Date •
Datum'
Voca.tion'\l Course
Aui-ibildungsk'^r J
_
'Vill not bo adnii/oud to Roh?:b .Contor at
Vorv/cigcrung d..airnai'JBc i;n iiuhab.CorltGr in
•
"horn
Hanc ci, ^\-u=j.cso.idcn
If propT.2' _/V i ollo'./ini" I'in •! dccloiDn -iT.s ^uvc.n atato:
V.'cnn i;a
:;n cn'j(lii._sc '•QSjjrc-.u.iung Vorbcrcitung (5i.;,:;cban \vird
folgo^ido Angabon;
I'ypQ of I'rcparaiicr.
nrt dcr Torboroit.u'n^;
''••• v/aoi-i
(."u.:&cn v.on
Poriod of tir.c
Zcit;jpu:--no
Dcccrihc- P.crsults:
PcGci.roibung dcs F.'JGUI:. ts .
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