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:

____________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

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.)

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

VIII. DIMENSIONES:

COMPORTAMENTAL: _________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________
 AFECTIVA: __________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________
SOMATICA: _________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
COGNITIVA: _________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
SOCIAL: ____________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

IX. PRUEBA Y ANLISIS DE RESULTADOS:

PERSONALIDAD: _____________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
INTELIGENCIA: ______________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
HABILIDADES: _______________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
OTRAS: _____________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

X. IMPRESIN DIAGNSTICA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

XI. TRATAMIENTO A SEGUIR:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

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: ____________________________________

 CONTROL DE CAMBIOS

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

03 - Inclusin de Documento de identidad.