HISTORIA CLINICA PSICOLOGICA

1. DATOS DE IDENTIFICACION

NOMBRE DEL CONSULTANTE: EDAD:

DIRECCIÓN:
TELÉFONO:
OCUPACIÓN:
ENTIDAD:

NOMBRE DEL ACUDIENTE: EDAD:

PARENTALIDAD:
OCUPACIÓN:

2. HISTORIA CLINICA

I. MOTIVO DE CONSULTA
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II. REMISIÓN
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III. ACONTECIMIENTOS Y EXPERIENCIAS SIGNIFICATIVAS EN LA HISTORIA

INDIVIDUAL, FAMILIAR Y/O CONTEXTUAL
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IV. TRATAMIENTOS MÉDICOS, PSICOLÓGICOS O PSIQUIÁTRICOS.

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V. GENOGRAMA

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 VI. DESCRIPCIÓN DEL PROBLEMA POR EL CONSULTANTE
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VII. DIAGNOSTICO (CIE -10)

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VIII. COMPRENSIONES DEL CASO

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IX. OBJETIVO(S) INTERVENTIVO(S)

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X. ESTRATEGIAS GENERALES DE INTERVENCIÓN

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XI.
NUMERO DE SESIONES
TIEMPO DEL TRATAMIENTO
PSICOTERAPÉUTICO

FIRMA PROFESIONAL FIRMA DEL CONSULTANTE