NOUS

HISTORIA PEDAGGICA AFECTIVA N. ______

FECHA: _______________________________
DATOS PERSONALES
Nombres y Apellidos: _________________________________________________
T.I. o C.C.: ___________________________ de: ___________________________
Fecha de Nacimiento: __________________________ Edad:__________________
Telfono :_______________ E mail:_____________________________________
Escolaridad: Primaria

Secundaria

Universidad

Especializacin

ltimo nivel cursado: ____________________________________________

DATOS DE LOS PADRES

Nombres y Apellidos del padre : _________________________________________
C.C.: ____________________ Ocupacin: ________________________________
Estado civil: ____________Edad: __________ Telfono:_____________________
Celular______________________ E mail _________________________________
Direccin_________________________________ Ciudad:___________________
Nombres y Apellidos de la madre : _______________________________________
C.C.: ____________________ Ocupacin: ________________________________
Estado civil: ____________Edad: __________ Telfono:_____________________
Celular______________________ E mail _________________________________
Direccin__________________________________ Ciudad:___________________

NOUS

MOTIVO DE CONSULTA
Cul es la preocupacin por la cul se acercan al Centro?
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VALORACIN DE REAS DE AJUSTE
Fsico Biolgica (Desarrollo):
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Salud general, Diagnsticos especiales, Medicamentos (copia de
frmula):
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NOUS

Diagnsticos en Psicologa (con informe):

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Diagnsticos en Psiquiatra (con informe), Medicamentos (copia de
frmula):
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Familiar:
GENOGRAMA FAMILIAR

NOUS

FORMAS DE COMUNICACIN: LMITES Y ESTRUCTURA

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Notas sobre el sistema familiar: _______________________________
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Vocacional (Acadmico Laboral):
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Social (Pares Grupos):
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NOUS

Afectivo Sexual:
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PLAN DE ACCIN INMEDIATO
1.
2.
3.
4.
HIPTESIS DE TRABAJO
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PLAN DE INTERVENCIN
COMPONENTE AFECTIVO:
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NOUS

COMPONENTE COGNITIVO:
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COMPONENTE EXPRESIVO:
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