PRIMERA ENTREVISTA

FECHA: _________________________

1. DATOS GENERALES

NOMBRE: _________________________________________________________________
EDAD: ________________ SEXO:_____________

OCUPACIN: __________________

ESCOLARIDAD:________ INSTITUCION EDUCATIVA:____________________________

DOMICILIO: _______________________________________________________________
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TELEFONO FIJO: _______________ TELEFONO CELULAR:_______________________
REMITIDO POR: ____________________________________________________________
MOTIVO: __________________________________________________________________
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2. DATOS ACOMPAANTE
NOMBRE: _________________________________________________________________
EDAD: ________________ SEXO: ____________

OCUPACIN: __________________

DOMICILIO: _______________________________________________________________
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TELEFONO FIJO: ________________ TELEFONO CELULAR: ______________________

3. ANAMNESIS
3.1 PSICOGRAMA

4. MOTIVO DE CONSULTA
Presente virtual. (Frecuencia, duracin, intensidad)
Qu fue lo ltimo que ocurri para que decidiera venir al psiclogo?
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5. CUADRO CLINICO
Desde cuando empez el problema? (presente virtual) __________________________
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Como fue la ultima ocasin en que ocurri el problema?_________________________

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Qu ocurra en su vida antes de que surgiera la situacin? (factores

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5.1 FACTORES DESENCADENANTES:

Qu otros aspectos se vinculan con el problema? (ncleo)

FACTOR
ASOCIADO

FAMILIA

PAREJA

AMISTADES

ESCUELA

TRABAJO

SALUD
FISICA

DESCRIPCION

5.2 SOPORTE FAMILIAR, SOCIAL, LABORAL, PERSONAL (Andamiaje)

Autovaloracin: ____________________________________________________________
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Sueos y fantasas ms frecuentes: ___________________________________________
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Satisfaccin conyugal o de pareja: ____________________________________________
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Satisfaccin laboral o de estudios: ____________________________________________
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Situaciones, actividades y personas con las que se siente ms tranquilo: ___________
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Actividades gratificantes que realiza: __________________________________________
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6.Describa las actividades que realiza cotidianamente de lunes a vienes y

fines de semana
LUNES____________________________________________________________________
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MARTES __________________________________________________________________
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MIERCOLES _______________________________________________________________
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JUEVES___________________________________________________________________
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VIERNES _________________________________________________________________
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SABADO__________________________________________________________________
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DOMINGO_________________________________________________________________
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7. CONTEXTO DE VIDA
ETAPA DE LA INFANCIA 0 5 AOS ( ASPECTOS: 1.SALUD FISICA 2.ESCOLAR
3.AMISTADES 4.FAMILIA 5.PERSONALIDAD 6.PAREJA 7.TRABAJO)
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7. CONTEXTO DE VIDA
ETAPA DE LA NIEZ 6 12 AOS ( ASPECTOS: 1.SALUD FISICA 2.ESCOLAR
3.AMISTADES 4.FAMILIA 5.PERSONALIDAD 6.PAREJA 7.TRABAJO)
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7. CONTEXTO DE VIDA
ETAPA DE LA ADOLESCENCIA 13 18 AOS ( ASPECTOS: 1.SALUD FISICA
2.ESCOLAR 3.AMISTADES 4.FAMILIA 5.PERSONALIDAD 6.PAREJA 7.TRABAJO)
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7. CONTEXTO DE VIDA
ETAPA DE LA JUVENTUD 18 - 35 AOS (ASPECTOS: 1.SALUD FISICA
2.ESCOLAR 3.AMISTADES 4.FAMILIA 5.PERSONALIDAD 6.PAREJA 7.TRABAJO)
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7. CONTEXTO DE VIDA
ETAPA DE LA ADULTEZ 35 AOS EN ADELANTE ( ASPECTOS: 1.SALUD
FISICA

2.ESCOLAR

3.AMISTADES

4.FAMILIA

5.PERSONALIDAD

6.PAREJA

7.TRABAJO)
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8. CONCLUSIONES
8.1 CONCLUSIONES EVIDENTES: (Lo que esta claro)
DESCRIPCION - Dimensin principal - Duracin, frecuencia, intensidad.
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Por qu se genero? - Causas, antecedentes histricos.
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Por qu se mantiene? - Factores involucrados.
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Relacin entre los diferentes problemas.
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Recomendaciones Tcnicas, sugerencias, etc.

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8.2 CONCLUSIONES HIPOTTICAS: (Lo que hay que comprobar)

DESCRIPCION - Dimensin principal - Duracin, frecuencia, intensidad.
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Por qu se genero? - Causas, antecedentes histricos.
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Por qu se mantiene? - Factores involucrados.
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Relacin entre los diferentes problemas.
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Recomendaciones Tcnicas, sugerencias, etc.

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9.1

PRONOSTICO A (SIN PSICOTERAPIA)

FACTORES RELEVANTES
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TENDENCIAS
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ESCENARIO 1 (Lo ms probable)
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PLAZO (Corto Mediano - Largo)
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ESCENARIO 2 (En el mejor de los casos)
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PLAZO (Corto Mediano - Largo)

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9. 2

PRONOSTICO B (CON PSICOTERAPIA)

FACTORES RELEVANTES
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RECURSOS POSITIVOS
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ESCENARIO 3 (Lo ideal a lograr con psicoterapia)
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PLAZO (Corto Mediano - Largo)
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ESCENARIO 4 (Lo mnimo que se espera lograr con psicoterapia)
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PLAZO (Corto Mediano - Largo)

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10.1. ANALISIS SEMIOTICO

Marca con una X.
o ASPECTO CORPORAL:
Complexin, edad que corresponde al aspecto fsico, gesticulacin, talla

baja o alta,

delgadez, exceso de peso, mano y uas limpias, etc.

o ARREGLO PERSONAL:
Arreglo, desalio, olor, vestido, maquillaje, peinado, accesorios, calzado, etc.
o COMPORTAMIENTO:
Lenguaje, se precipita en sus respuestas ,silencios , tono de voz, palabras rebuscadas,
calo, gestos, relajado, tenso, llanto, bostezo,

conversador, contacto visual,

expresin

facial concuerda con mensaje verbal, sonrisa, distancia que guarda al sentarse, postura
cmoda,

posturas abatidas o de decaimiento, cabeza alta, espalda

recta, brazos

apoyados en el asiento, movimiento excesivo de manos, forma de sentarse

o DESCRIPCION GENERAL:
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ASPECTO CORPORAL
COMPLEXIN
EDAD
APARENTE

Talla baja

Talla alta

Exceso de
peso

delgadez

menor

mayor

o NIVEL DE EMPATIA:
E____
R____

10.2. ANALISIS SEMIOTICO.

ESTILO DE VESTIR
BIEN

REGULAR

MAL

DEPORTIVO
FORMAL
CASUAL
ALIO

ARREGLO PERSONAL
CUIDADO

DESCUIDADO

CABELLO
UAS
MAQUILLAJE
HIGIENE
OLOR
AGRADABLE DESAGRADALE

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EMOCIONES
COMPORTAMIENTO
Miedo
Confiado
desconfiado
Alegra
Extrovertido
introvertido
Tristeza
tranquilo
inquieto
Enojo
cooperador
renuente
Amor
interesado
aptico
amable
descorts
relajado
tenso

B____

POSTURA
Cmoda
Piernas cruzadas
Piernas
abatido
extendidas
Movimiento
decado
excesivo de
manos
Espalda
rigidez
encorvada
Distancia que
Espalda recta
guarda al
sentarse
Brazos
apoyados
Brazos
cruzados

INTERPRETACION GENERAL:

LENGUAJE
Precipita en sus
Contacto visual
respuestas
Expresin facial
Silencios
concuerda con
mensaje verbal
Palabras
Aumento de voz
rebuscadas
Calo
Voz baja
Gesticulacin
Conversador
Bostezo

NIVEL DE EMPATIA
EXCELENTE
MUY BUENO
BUENO
REGULAR
MALO

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ENTREVIST:

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