INSTITUSI PENERIMA WAJIB LAPOR

YAYASAN PUSAT REHABILITASI NARKOBA

AR RAHMAN
(SK.Menteri Sosial RI No.31/HUK/2012 , No.36/HUK/2013, No.41/HUK/2014 No.40/HUK/2015)
Jalan Tegal Binangun Komplek Ponpes Ar Rahman RT. 35 RW. 10 Kelurahan Plaju Darat
Kecamatan Plaju Kota Palembang Provinsi Sumatera Selatan
HP: 0812 7364021 Email: rehabilitasinarkoba.arrahman@gmail.com

LAPORAN HASIL PEMERIKSAAN PSIKOLOGI KLIEN

I. IDENTITAS
1. Identitas Subjek
Nama : ............................................................................................................................
Jenis Kelamin : ........................................................................................................................
Tempat/Tgl. Lahir : ............................................................................................................................
Suku Bangsa : ............................................................................................................................
Agama : ..................................... ...................................................................................
Anak ke : .......... dari .................... bersaudara
Status Perkawinan : ............................................................................................................................
Pendidikan : ............................................................................................................................
Pekerjaan : ...........................................................................................................................
Alamat : ............................................................................................................................

2. Identitas Pemeriksa
Nama Pemeriksa : ............................................................................................................................
NIK : ............................................................................................................................
Tujuan Pemeriksaan : ............................................................................................................................
Tempat Pemeriksaan: Pusat Rehabilitasi Narkoba Ar Rahman
Tanggal Pemeriksaan : ............................................................................................................................

II. KELUHAN
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 INSTITUSI PENERIMA WAJIB LAPOR
YAYASAN PUSAT REHABILITASI NARKOBA
AR RAHMAN
(SK.Menteri Sosial RI No.31/HUK/2012 , No.36/HUK/2013, No.41/HUK/2014 No.40/HUK/2015)
Jalan Tegal Binangun Komplek Ponpes Ar Rahman RT. 35 RW. 10 Kelurahan Plaju Darat
Kecamatan Plaju Kota Palembang Provinsi Sumatera Selatan
HP: 0812 7364021 Email: rehabilitasinarkoba.arrahman@gmail.com

III. RIWAYAT KELUHAN

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IV. STATUS PRAESENS

1. STATUS FISIK
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 INSTITUSI PENERIMA WAJIB LAPOR
YAYASAN PUSAT REHABILITASI NARKOBA
AR RAHMAN
(SK.Menteri Sosial RI No.31/HUK/2012 , No.36/HUK/2013, No.41/HUK/2014 No.40/HUK/2015)
Jalan Tegal Binangun Komplek Ponpes Ar Rahman RT. 35 RW. 10 Kelurahan Plaju Darat
Kecamatan Plaju Kota Palembang Provinsi Sumatera Selatan
HP: 0812 7364021 Email: rehabilitasinarkoba.arrahman@gmail.com

2. STATUS PSIKIS
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V. OBSERVASI
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 INSTITUSI PENERIMA WAJIB LAPOR
YAYASAN PUSAT REHABILITASI NARKOBA
AR RAHMAN
(SK.Menteri Sosial RI No.31/HUK/2012 , No.36/HUK/2013, No.41/HUK/2014 No.40/HUK/2015)
Jalan Tegal Binangun Komplek Ponpes Ar Rahman RT. 35 RW. 10 Kelurahan Plaju Darat
Kecamatan Plaju Kota Palembang Provinsi Sumatera Selatan
HP: 0812 7364021 Email: rehabilitasinarkoba.arrahman@gmail.com

VI. ANAMNESA
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 INSTITUSI PENERIMA WAJIB LAPOR
YAYASAN PUSAT REHABILITASI NARKOBA
AR RAHMAN
(SK.Menteri Sosial RI No.31/HUK/2012 , No.36/HUK/2013, No.41/HUK/2014 No.40/HUK/2015)
Jalan Tegal Binangun Komplek Ponpes Ar Rahman RT. 35 RW. 10 Kelurahan Plaju Darat
Kecamatan Plaju Kota Palembang Provinsi Sumatera Selatan
HP: 0812 7364021 Email: rehabilitasinarkoba.arrahman@gmail.com

VII. KESIMPULAN SEMENTARA

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VIII. DIAGNOSA
AXIS I : ........................................................................................................................................
AXIS II : ........................................................................................................................................
AXIS III : ........................................................................................................................................
AXIS IV : ........................................................................................................................................
AXIS V : ........................................................................................................................................

IX. RANCANGAN INTERVENSI

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