HOJA DE ATENCIN PSICOLGICA PARA INSTITUCIN EDUCATIVA

Historia clnica :______________________________ Fecha de la Primera sesin:

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Nombre del referente:_________________________________________
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Nombre del Psiclogo que entrevista
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Tutor Entrevistador. PSIC Yamily Gmez Delgado

I -DATOS DE FILIACIN:

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Fecha de nacimiento: ______________________Nmero de hermanos : _______________________
Domicilio :_______________________________________________________________
Informante : _______________________________________________________________________

II MOTIVO DE CONSULTA:
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III ANTECEDENTES:

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IV OBSERVACIN DE LA CONDUCTA:

1 Observacin de la conducta por parte de la madre, padre o tutor

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2 Observacin de la conducta por parte de la profesora:

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3 Observacin de la conducta al paciente:

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V ANTECEDENTES FAMILIARES Y SOCIALES

Retardo mental ( ) Depresin ( ) Ansiedad ( ) Esquizofrennia ( ) Bajo rendimiento escolar ( )

Baja autoestima ( ) Otros

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HISTORIA FAMILIAR:

PADRE: MADRE:

EDAD: ...
G. I. :. ..
OCUP:
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HIJOS:
RELIG:
DOMIC.: .

HERMANOS:
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VI - PRUEBAS APLICADAS:
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VII RECOMENDACIONES
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VIII HOJA DESEGUIMIENTO:

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FIRMA Y SELLO

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FIRMA Y SELLO

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FIRMA Y SELLO