‫ﻣﺠﻤﻮﻋﺎت ﻗﻤﺔ اﻟﺘﻤﻴﺰ اﻟﺘﻌﻠﻴﻤﻴﺔ‪.....

‬ﺳﺮ وﺻﻮﻟﻚ ﻧﺤﻮ اﻟﺘﻤﻴﺰ‪ɶɶɶɶ‬‬

‫دراﺳﺔ ﺣﺎﻟﺔ‬

‫اﺳﻢ اﻟﻄﺎﻟﺐ ورﻣﺰه ‪................................... :‬‬

‫اﻟﺺـــــــــف‪............................................ :‬‬
‫ﻣﺼﺪر اﻟﺘﺤﻮﻳﻞ وﺗﺎرﻳﺨﻪ‪................................................................ :‬‬

‫ﻧﻮع اﻟﺤﺎﻟﺔ‪.............................................. :‬‬

‫‪2019/‬‬ ‫‪/‬‬ ‫ﺗﺎرﻳﺦ اﻟﺒﺪء ﻣﻊ اﻟﺤﺎﻟﺔ ‪:‬‬ ‫‪( ..........‬‬ ‫)‬ ‫رﻗﻢ اﻟﺤﺎﻟﺔ‬
‫‪ 2020 / 2019‬م‬ ‫اﻟﻌﺎم اﻟﺪراﺳﻲ ‪:‬‬

‫ﻣﺪﻳﺮ اﻟﻤﺪرﺳﺔ‬ ‫اﻷﺧﺼﺎﺋﻲ اﻻﺟﺘﻤﺎﻋﻲ‬

‫ﻓﻬﺪ ﻋﻘﺎب اﻟﺸﻤﺮي‬ ‫أﺣﻤﺪ ﻓﺎروق أﻣﻴﻦ‬
 ‫اﻟﻤﻌﻠﻮﻣﺎت اﻷوﻟﻴﺔ ﻋﻦ اﻟﻄﺎﻟﺐ‪:‬‬

‫اﻟﺠﻨﺴﻴﺔ‬ ‫اﺳﻢ اﻟﻄﺎﻟﺐ‬

‫رﻗﻢ اﻟﺘﻠﻴﻔﻮن‪:‬‬ ‫ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‬
‫اﻟﻌﻨﻮان‬

‫أﻋﻀﺎء ﻓﺮﻳﻖ دراﺳﺔ اﻟﺤﺎﻟﺔ‪:‬‬

‫اﻟﺘﻮﻗﻴﻊ‬ ‫اﻟﻮﻇﻴﻔﺔ‬ ‫اﻻﺳﻢ‬

‫اﻟﺒﻴﺎﻧﺎت اﻷﺳﺮﻳﺔ ﻟﻠﻄﺎﻟﺐ‪:‬‬

‫(‬ ‫ﻻ)‬ ‫(‬ ‫ﻫﻞ ﻫﻨﺎك ﻃﻔﻞ أﺧﺮ ﻧﻔﺲ اﻟﺤﺎﻟﺔ ﻓﻲ اﻷﺳﺮة أو اﻟﻌﺎﺋﻠﺔ‪ :‬ﻧﻌﻢ )‬

‫ﺻﻠﺔ اﻟﻘﺮاﺑﺔ ﺑﻴﻦ اﻷب واﻵم‪............................................ :‬‬

‫‪.‬‬
‫ﻋﻼﻗﺔ اﻟﻄﺎﻟﺐ ﺑﺎﻷﺳﺮة‪(... .................................................................... ) :‬‬
‫( ﻣﻊ واﻟﺪﺗﻪ ) ( أﺧﺮى ﺗﺬﻛﺮ ‪............................ :‬‬
‫( ﻣﻊ واﻟﺪه ﻓﻘﻂ )‬ ‫( ﻣﻊ واﻟﺪﻳﻪ )‬ ‫ﻣﻊ ﻣﻦ ﻳﻌﻴﺶ اﻟﻄﺎﻟﺐ ؟ )‬
‫(‬ ‫ﺗﺮﺗﻴﺐ اﻟﻄﺎﻟﺐ ﻓﻲ اﻟﻤﻴﻼد ﺑﻴﻦ أﺧﻮﺗﻪ وأﺧﻮاﺗﻪ )‬
‫ﻋﺪد أﻓﺮاد اﻷﺳﺮة اﻟﻌﺎﻣﻠﻴﻦ‪:‬‬
‫(‬ ‫إﻧﺎث )‬ ‫(‬ ‫ﻋﺪد أﻓﺮاد اﻷﺧﻮة ‪ :‬ذﻛﻮر )‬
‫(‬ ‫ﻋﺪد أﻓﺮاد اﻷﺳﺮة ‪) :‬‬
‫اﻟﺤﺎﻟﺔ اﻻﺟﺘﻤﺎﻋﻴﺔ ‪:‬‬
 ‫ﺳﻨﻮات اﻟﺮﺳﻮب ‪(........................... ) :‬‬

‫ﻣﻘﺒﻮل )‬ ‫(‬ ‫ﺟﻴﺪ )‬ ‫(‬ ‫( ﺟﻴﺪ ﺟﺪا )‬ ‫اﻟﻤﺴﺘﻮي اﻟﺪراﺳﻲ ﺧﻼل اﻟﻌﺎم اﻟﺪراﺳﻲ ‪ :‬ﻣﻤﺘﺎز )‬
‫( ) ‪( .............................................................................‬‬ ‫ﺿﻌﻴﻒ )‬ ‫(‬

‫اﻟﺪوام اﻟﻤﺪرﺳﻲ‬

‫ﻋﺪد أﻳﺎم اﻟﻐﻴﺎب) ‪ ( ...........‬ﻳﻮﻣًﺎ ‪ /‬أﻳﺎم ‪ ----‬ﺣﺼﺔ ‪ -----‬اﻟﻤﺠﻤﻮع ) ‪ ( ..............‬ﻳﻮﻣًﺎ ‪ /‬أﻳﺎم‬

‫ﻋﺪد‬

‫أﻳﺎم اﻟﻔﺼﻞ إن وﺟﺪت‪................................................................................................... :‬‬

‫أﺧﺮى ) ‪( ................‬‬ ‫إﻳﺠﺎر ) ‪( ..............‬‬ ‫(‬ ‫وﺻﻒ اﻟﻤﺴﻜﻦ ‪ :‬ﺧﺎص ) ‪..........‬‬

‫اﻟﺤﺎﻟﺔ اﻻﻗﺘﺼﺎدﻳﺔ ﻟﻸﺳﺮة‪................................................................................................................... :‬‬

‫) ‪( ............................‬‬ ‫اﻷم‬ ‫اﻷب ) ‪( .......................‬‬ ‫اﻟﺤﺎﻟﺔ اﻟﺘﻌﻠﻴﻤﻴﺔ‪:‬‬

‫اﻟﻮﺿﻊ اﻟﺤﺎﻟﻲ ﻟﻠﻄﺎﻟﺐ ‪:‬‬

‫اﻟﻌﻼﻗﺎت اﻷﺳﺮﻳﺔ‪.......................................................................................................... :‬‬

‫ﻋﻼﻗﺔ اﻟﻄﺎﻟﺐ اﻻﺟﺘﻤﺎﻋﻴﺔ‪................................................................................................. :‬‬

‫اﻟﺴﻤﺎت اﻟﺸﺨﺼﻴﺔ ﻟﻠﻄﺎﻟﺐ‪................................................................................................ :‬‬

‫اﻟﺤﺎﻟﺔ اﻟﺼﺤﻴﺔ ﻟﻠﻄﺎﻟﺐ‪.................................................................................................. :‬‬

‫ﻧﺸﺎﻃﺎت اﻟﻄﺎﻟﺐ وﻫﻮاﻳﺎﺗﻪ‪.............................................................................................. :‬‬

‫ﻣﺸﻜﻼت اﻟﻄﺎﻟﺐ اﻟﺴﺎﺑﻘﺔ‪............................................................................................... :‬‬

‫اﻟﻤﺸﻜﻼت اﻟﺤﺎﻟﻴﺔ ﻟﻠﻄﺎﻟﺐ‪.......................................................................................... :‬‬

‫اﻟﺘﺎرﻳﺦ اﻟﺘﻄﻮري ﻟﻠﺤﺎﻟﺔ‪............................................................................................ :‬‬

 ‫ﺗﺸﺨﻴﺺ اﻟﺤﺎﻟﺔ‬
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‫اﻟﺨﻄﺔ اﻟﻌﻼﺟﻴﺔ‬
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‫ﻣﺘﺎﺑﻌﺔ اﻟﺤﺎﻟﺔ‬
‫‪/‬‬ ‫‪/‬‬ ‫( ﺑﺘﺎرﻳﺦ‬ ‫اﻟﻤﺘﺎﺑﻌﺔ )‬

‫ﻣﻠﺨﺺ اﻟﻤﻘﺎﺑﻠﺔ ) ‪(.......................................................................................................‬‬

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 ‫‪/‬‬ ‫‪/‬‬ ‫( ﺑﺘﺎرﻳﺦ‬ ‫اﻟﻤﺘﺎﺑﻌﺔ )‬

‫ﻣﻠﺨﺺ اﻟﻤﻘﺎﺑﻠﺔ‪( .................................................................................................... ) :‬‬

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‫‪/‬‬ ‫‪/‬‬ ‫( ﺑﺘﺎرﻳﺦ‬ ‫اﻟﻤﺘﺎﺑﻌﺔ )‬

‫اﻟﻤﻘﺎﺑﻠﺔ‪(....................................................................................................... ) .‬‬ ‫ﻣﻠﺨﺺ‬

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‫‪/‬‬ ‫‪/‬‬ ‫( ﺑﺘﺎرﻳﺦ‬ ‫اﻟﻤﺘﺎﺑﻌﺔ رﻗﻢ )‬

‫ﻣﻠﺨﺺ اﻟﻤﻘﺎﺑﻠﺔ ‪(............................................................................................................ ) :‬‬

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 ‫إﺟﺮاءات ﺗﻢ ﺗﻨﻔﻴﺬﻫﺎ ﻣﻊ اﻟﻄﺎﻟﺐ ﺧﻼل ﻣﺘﺎﺑﻌﺘﻪ‬
‫اﻟﻬﺪف ﻣﻨﻪ‬ ‫اﻟﺘﺎرﻳﺦ‬ ‫اﻹﺟﺮاء‬ ‫م‬
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‫ﻣﺪﻳﺮ اﻟﻤﺪرﺳﺔ‬ ‫م ‪ /‬ﺷﺆون اﻟﻄﻼب‬ ‫اﻷﺧﺼﺎﺋﻲ اﻻﺟﺘﻤﺎﻋﻲ‬