FORMATO DE HISTORIA CLINICA

No DE HISTORIA

NOMBRES

ESTADO CIVIL

PSICOLOGICA

Cdigo: GB-FO-004

GESTIN DE BIENESTAR
INSTITUCIONAL

Versin: 01

FECHA

LUGAR

IDENTIFICACIN DEL CONSULTANTE

APELLIDOS
CEDULA

DIRECCION

TELEFONO

FECHA DE
NACIMIENTO
OCUPACION

COMPOSICION FAMILIAR
N
NOMBRE
PARENTESCO EDAD TELEFONO OCUPACION
1
2
3
4
5
6
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CONTACTO PREVIO CON PROFESIONAL EN SALUD MENTAL
CUAL______________________________

SI____ NO____

HISTORIA FAMILIAR (ASPECTOS ESTRUCTURAL Y FAMILIAR)

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FORMATO DE HISTORIA CLINICA

PSICOLOGICA

Cdigo: GB-FO-004

GESTIN DE BIENESTAR
INSTITUCIONAL

Versin: 01

ANTECEDENTES MEDICOS Y/O PSICOLOGICOS

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HISTORIA PERSONAL
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HISTORIA DEL PROBLEMA
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PENSAMIENTO, CONDUCTA, EMOCIN

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FORMATO DE HISTORIA CLINICA

PSICOLOGICA

Cdigo: GB-FO-004

GESTIN DE BIENESTAR
INSTITUCIONAL

Versin: 01

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DIAGNOSTICO
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Realizado por ___________________

PSICLOGA PRACTICANTE

VoBo ________________________
ASESORA DE PRCTICA

FORMATO DE HISTORIA CLINICA

PSICOLOGICA

Cdigo: GB-FO-004

GESTIN DE BIENESTAR
INSTITUCIONAL

Versin: 01

PLAN DE TRATAMIENTO
MODELO TERAPEUTICO

OBJETIVOS DEL TRATAMIENTO

NUMERO DE SESIONES: ____________

PRUEBAS

INTERPRETACION

FORMATO DE HISTORIA CLINICA

PSICOLOGICA

Cdigo: GB-FO-004

GESTIN DE BIENESTAR
INSTITUCIONAL

Versin: 01

HOJA DE EVALUACIONES
SESION

FECHA

INTERVENCION

FIRMA DEL
PACIENTE