RAHASIA

CONTOH

Drs. Zaenuddin S.K. M. Psi

PROGRAM PENDIDIKAN MAGISTER PSIKOLOGI PROFESI (P2MPP)

FAKULTAS PSIKOLOGI
UNIVERSITAS PERSADA INDONESIA
JAKARTA

LAPORAN PEMERIKSAAN PSIKOLOGIS

( Harap Disimpan Sebagai Dokuman Rahasia )

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DATA PEMERIKSAAN PSIKOLOGIS

I. Identitas subyek

Nama Lengkap :
Nama Panggilan :
Jenis Kelamin :
Tempat tanggal lahir :
Agama :
Suku bangsa :
Alamat Lengkap :
Pendidikan terakhir :
Pekerjaan :
Rujukan :
Tujuan Pemeriksaan :
Tanggal Pemeriksaan :
Pemeriksa :
Pembimbing lapangan :
Pembimbing laporan :

II. PERSOALAN / KELUHAN

( Agar dicari gejala / penyakit / simtom yang pernah dialami sejak kecil dan cara
pengobatannya )
1. Hasil Pemeriksaan Dokter / Ahli lain :
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2. Diagnosis Dokter :
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3. Faktor resiko (Sering pingsan, epilepsy, agresi, sering kabur)

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4. Penampilan Diri
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III. KEADAAN KELUARGA

1. Oarangtua Wali Lainnya : _____________

Ayah : Kandung Ibu : Kandung

Tiri Tiri

Angkat Angkat

Nama lengkap : _________________ Nama lengkap : _________________

Alamat Lengkap : _________________ Alamat Lengkap : _________________
Tempat/tgl Lahir : _________________ Tempat/tgl Lahir : _________________
Suku Bangsa : _________________ Suku Bangsa : _________________
Agama : _________________ Agama : _________________
Status Perkawinan : _________________ Status Perkawinan : _________________
Pendidikan Terakhir : _________________ PendidikanTerakhir : _________________
Pekerjaan Terakhir : _________________ Pekerjaan Terakhir : _________________

2. Tanggungan Keluarga
( Tuliskan urutan nama saudara termasuk subyek sendiri )

No. Nama Lengkap Umur Pendidikan Pekerjaan Keterangan

1.
2.
3.
4.
5.
6.

3. Keadaan Pribadi Subyek

Status Perkawinan : Kawin / Belum Kawin / Duda / Janda / Cerai
Jumlah Anak :
Nama Suami / Istri :
Umur Suami / Istri :
Suku Bangsa :
Agama :
Pendidikan Terakhir :
Pekerjaan Terakhir :
Status Sosial / Ekonomi :
Keterangan lain-lain :
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Genogram ( Silsilah dalam keluarga )

4. Pendidikan Subyek
Tingkat Tempat Masuk / Keluar Keterangan
SD
SMP
SMU
Kejuruan
S1
S2
S3

5. Kursus / Pendidikan yang pernah diikuti

No Kursus Tempat Masuk / Keluar Keterangan

6. Pengalaman Kerja / Dinas

Tempat kerja Jabatan Terakhir Masuk / Keluar Keterangan

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7. Bahasa Sehari-hari : ___________________________________

Bahasa daerah yang di kuasai : ___________________________________
Bahasa asing yang dikuasai : ___________________________________
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8. Hobi / Kegemaran : 1. ________________________________

2. ________________________________
3. ________________________________

9. Kegiatan Sosial / Keagamaan

 _____________________________
 _____________________________
 _____________________________

10. Keterangan lain Berdasarkan Autoanamnesis (2-4 Halaman)

@ Tingkat-tingkat / fase-fase perkembangan
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@ Penyakit yang pernah diderita / penyakit keturunan

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@ Tinggal dan dibesarkan oleh siapa

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@ Situasi rumah dan penghuninya bagaimana

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@ Kebiasaan-kebiasaan baik / buruk, cita-cita / keinginan

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@ Peristiwa yang relevan dalam mengadakan hubungan interpersonal, konflik-konflik,

trauma, dsb.
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11. Keterangan Lain Berdasarkan Alloanamnesis (2 halaman)

( Perhatikan relevansinya dengan keterangan yang berdasarkan Autoanamnesis )
Di peroleh dari :
Nama Lengkap : ___________________________________________
Alamat Lengkap : ___________________________________________
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Usia : ___________________________________________
Pendidikan Terakhir : ___________________________________________
Pekerjaan Terakhir : ___________________________________________
Hubungan dengan subyek : ___________________________________________

Uraian Cerita:
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12. Observasi (2 halaman)

(Diambil melalui anamnesis atau hasil interview dari subyek)
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Check List

(Untuk membantu observasi dapat digunakan check list dari observasi perilaku subyek)

a. Sikapterhadappemeriksa

1. Kooperatif Tidak kooperatif

2. Pasif Agresif

3. Tegang Rileks

4. Mudah Bangkit Susah bangkit

b. Sikap terhadap diri

1. Percaya diri Tidak percaya diri

2. Mengkritik diri Menerima diri

c. Kebiasaan kerja

1. Cepat Lambat

2. Tertib Ceroboh

3. Berpikir Subyek Berpikir tenang

4. Hati-hati Gusar

d. Perilaku

1. Tenang Aktif

2. Responsive Tidak responsive

e. Reaksi terhadap kesalahan

1. Menerima kesalahan Tidak menerima masalah

2. Kerja keras setelah salah Biasa saja setelah salah

3. Tenang setelah salah Agitasi setelah salah

4. Minta maaf setelah salah Tidak minta maaf

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12. Analisis Biografi

Waktu Kejadian Reaksi

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13. Dinamika Perkembangan

a. Perkembangan masa kanak-kanak

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b. Perkembangan masa sekolah

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c. Perkembangan masa remaja

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d. Perkembangan masa dewasa

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e. Kebutuhan-kebutuhan terpenuhi / tidak

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f. Potensi-potensi yang dimiliki

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g. Hubungan sosial dengan saudara

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h. Hubungan sosial dengan kawan

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i. Hubungan sosial dengan orangtua

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j. Hubungan sosial dengan guru

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k. Perilaku-perilakunya
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l. Stress dari lingkungan

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m. Penyesuaian diri terhadap lingkungan

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IV. TES PSIKOLOGIS

No. Tanggal TES Observasi TES

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Keterangan Tambahan:
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V. RANGKUMAN HASIL TES PSIKOLOGI

No. ASPEK INTERPRETASI ALAT TES

1 INTELEGENSI

DORONGAN
2
DAN MOTIVASI

SIFAT DAN
3
KEPRIBADIAN

KEHIDUPAN
4
EMOSI

HUBUNGAN
5
ANTAR PRIBADI

HAMBATAN
6
(Dlm diri sendiri)

7 POLA ASUH
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DEFENCE
8
MECHANISM

VI. ANALISA KASUS

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TEORI

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VII. HASIL PEMERIKSAAN PSIKOLOGIS (INTEGRATED)

1. Diagnosis dari Dokter

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2. Diagnosis Multiaksial
Axis 1 : ______________________________________________________________
Axis 2 : ______________________________________________________________
Axis 3 : ______________________________________________________________
Axis 4 : ______________________________________________________________
Axis 5 : ______________________________________________________________
3. Kesimpulan
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4. Treatment Dalam Psikologi

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5. Prognosis
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