ENTREVISTA DE ADULTOS

Fecha: ___________________________________________________________________

Nombre:__________________________________________________________________

Fecha de Nacimiento: __________________________ Edad: _______________________

Estado Civil: _________________________________ Tiempo: ____________________

Nivel de Estudio: _____________________________ Profesión: ___________________

Lugar de Trabajo: _____________________________ Tiempo de Labor: _____________

Cargo que ocupa: _____________________________ Tiempo en el cargo: ____________

Dirección : _______________________________________________________________

Teléfonos : _______________________________________________________________

Genograma familiar

Motivo de Consulta:

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Antecedentes de la condición actual:

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Historia familiar:

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Antecedentes Familiar de Enfermedades:

Médicas:

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Psiquiátricas o Psicológicas:

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Relación con el cónyuge:

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Relación con los hijos:

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Relación con otras Personas:

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Relación con Jefes y Autoridades:

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Relación con los subordinados:

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Relación con compañeros de trabajo de igual jerarquía:

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Principales temores:

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Principales anhelos o deseos:

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Pasatiempos:

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ESTADO MENTAL:

Lenguaje : _________________________ Pensamiento: ___________________________

Memoria Reciente: __________________ Memoria Antigua: _______________________

Atención espontánea: ________________ Atención Procurada: _____________________

Orientación Espacial: ________________ Temporal: _____________________________

Juicio de Realidad:

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Control Emocional.:

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Nivel de Comunicación :

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Conclusiones:

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Recomendaciones:

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PRUEBAS SUGERIDAS:

Inteligencia Personalidad Habilidades e intereses

WISC: _______ MMPI: _______ GATB: _______

Raven: _______ TAT: _______ Brainer: _______

Dominoes: ________ Sack: _______ Jenkins: _______

Otras: _______ Machover: _______ Otras: ________

Rorschach: _______

Control de Visitas: Actividades:

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