Entrevista Psicológica para Adulto/a

1. Datos de Identificación:
Nombre_________________________________________________________
Edad _______________________Cédula _____________________________
Estado Civil ______________
Escolaridad_______________Ocupacion______________________________Do
micilio________________________________________________________Telefo
no________________ Derivación _______________________________
Fecha ____________________Terapeuta______________________________

2. Encuadre al entrevistado en donde se explica que primeramente se
realizará un recorrido por su historia familiar y las diferentes etapas dentro
del desarrollo de su vida.

3. Genograma

cuándo. Observaciones A) Queja inicial __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ B) Porque ahora ____________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ C) Motivo de la consulta ______________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ D) Historia y circunstancia actual del motivo de consulta (dónde. Por el paciente identificado _______________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ ___________________________________________ 2.4. Por los otros __________________________________________ _______________________________________________________ _______________________________________________________ ______________________________________________ . cómo. con quién) __________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ________________________________________ E) Que deja de hacer o quisiera hacer y no hace como consecuencia del problema ____________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________ F) SOLUCIONES INTENTADAS 1.

ACTITUDES Y OPINIONES IMPORTANTES DE LAS PERSONAS SIGNIFICATIVAS ___________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ______________________________________________ 8. POSICIONES Y LENGUAJE DEL CONSULTANTE QUE PUEDEN SER UTILES ___________________________________________________ ____________________________________________________________ ____________________________________________________________ .3. Exitosas _____________________________________________ _______________________________________________________ _________________________________________________ Se mantuvieron____________________________________________________ ________________________________________________________________ No se mantuvieron _________________________________________________ ___________________________________________________________________ _____________________________________________________________ ¿Porque fueron abandonadas? ______________________________________ ___________________________________________________________________ ___________________________________________________________________ __________________________________________________________ 5. TRATAMIENTOS ANTERIORES _______________________________ ____________________________________________________________ ________________________________________________________ A) Que sirvió _______________________________________________ __________________________________________________________ __________________________________________________________ _________________________________________________ B) Que no sirvió ____________________________________________ __________________________________________________________ __________________________________________________________ _________________________________________________ 6. TRATAMIENTOS ACTUALES ( de cualquier tipo que se consideren pertinentes) ________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ __________________________________________________ 7.

____________________________________________________________ ____________________________________________________ 9.META MINIMA PACTADA CON EL CONSULTANTE Y REACCION DE ESTE _____________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________ 12.DIAGNOSTICO _____________________________________________ ____________________________________________________________ ____________________________________________________________ ______________________________________________________ 11. MOTIVACION A) ¿Qué objetivos busca al consultar? ___________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ B) ¿Qué espera que haga el terapeuta? _________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________ 10.OBJETIVOS DEL TERAPEUTA Corto plazo ________________________________________________ ____________________________________________________________ ____________________________________________________________ ______________________________________________________ Mediano plazo ______________________________________________ ____________________________________________________________ ____________________________________________________________ ______________________________________________________ Largo plazo ________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ __________________________________________________ .

INTERVENCIONES DE ADMISOR Y PRIMERA REACCION DEL CONSULTATNTE A) Reformulaciones _________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ B) Prescripciones o sugerencias _______________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ C) Indicaciones de tipo de tratamiento y sus razones _______________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ 14.PREDICCIONES ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________ 15.NUMERO DE SESIONES PREVISTAS __________________________ 18.13.ESTRATEGIAS A SEGUIR ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________ 16.QUIENES SON CITADOS PARA LA PROXIMA SESION ____________________________________________________________ ________________________________________________________ 17.NUMEROS DE SESIONES REALIZADAS ________________________ ______________________________ Profesional .Firma .

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