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l. DATOS PERSONALES

No. Historia:____________ Fecha:_____________

Nombres:________________________________________
Apellidos:______________________________
Documento de identidad: T.I.___ C.C.___ No. _______________________________
Edad:______________ Sexo:__________ Estado Civil:______________
Lugar y fecha de
Nacimiento:________________________________________________________________
Carrera:_______________________ Cdigo:_______________ Semestre:___________
Nivel:________
Crditos cursados: ____________ Crditos Aprobados: ____________
Promedio Acumulado: ________ Promedio del Semestre Anterior: _______
Direccin actual:________________________________________________________________________
Telfono: _____________
Direccin de la Familia: _____________________________________
Ciudad:____________________
Telfono: _______________

Ha recibido algn tipo de tratamiento psicolgico o psiquitrico:

______________________________________________________________________________________

ll. MOTIVO DE CONSULTA:

_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

lll. DEFINICIN DEL PROBLEMA:

EVOLUCIN:______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

CAUSAS:__________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

ACCIONES REALIZADAS EN BUSCA DE SOLUCIN:

____________________________________________________
__________________________________________________________________________________________________
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__________________________________________________________________________________________________

IMPLICACIONES: (a nivel familiar, social, acadmico, etc.):

__________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

lV. ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:

FAMILIOGRAMA:

MIEMBRO PARENTESCO EDAD ESCOLARIDAD OCUPACIN

VINCULOS AFECTIVOS CONFLICTIVOS Y REDES DE COMUNICACIN:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

V. HISTORIA PERSONAL:

INFANCIA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

ADOLESCENCIA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

VI. HISTORIA ESCOLAR:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

VII. OBSERVACIONES: (descripcin fsica, lenguaje no verbal, actitud, etc.)

__________________________________________________________________________________________________
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__________________________________________________________________________________________________
__________________________________________________________________________________________________

VIII. DIMENSIONES:

COMPORTAMENTAL: ______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________
AFECTIVA: ________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________
SOMATICA:________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
COGNITIVA:_______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SOCIAL: __________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

IX. PRUEBA Y ANLISIS DE RESULTADOS:

PERSONALIDAD:___________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTELIGENCIA: ____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
HABILIDADES:_____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
OTRAS:___________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

X. IMPRESIN DIAGNSTICA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

XI. TRATAMIENTO A SEGUIR:

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__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
EVOLUCIN

Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________

Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________

Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________

Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________

Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________

Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________

EVALUACIN REALIZADA POR: ____________________________________

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 CONTROL DE CAMBIOS

FECHA DE
VERSIN DESCRIPCIN DE CAMBIOS REALIZADOS
APROBACIN
- Inclusin de Control de Cambios.
02 Abril 15 de 2009 - Inclusin de pgina y otros ajustes en el
encabezado.

03 Abril 23 de 2009 - Inclusin de Documento de identidad.