INFORME PSICOLÓGICO

I. DATOS GENERALES
. Nombres y Apellidos : …………………………………………………………………..
. Edad : …………………………………………………………………..
. Sexo : F M
. Fecha de nacimiento : …………………………………………………………………..
. Lugar de nacimiento : …………………………………………………………………..
. Número de hermanos : …………………………………………………………………..
. Lugar entre hermanos : …………………………………………………………………..
. Domicilio : …………………………………………………………………..
. Teléfono : …………………………………………………………………..
. Grado de instrucción : …………………………………………………………………..
. Estado civil : …………………………………………………………………..
. Fecha de evaluación : …………………………………………………………………..
. Entrevistador : …………………………………………………………………..

II. MOTIVO DE CONSULTA

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III. PROBLEMA ACTUAL

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IV. ANTECEDENTES (Datos relevantes)

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V. TECNICAS E INSTRUMENTOS UTILIZADOS

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VI. RESULTADOS
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VII. DIAGNÓSTICO FUNCIONAL

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VIII. DIAGNÓSTICO MULTIAXIAL

Eje I: _____________________________________________________________________
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Eje II: ____________________________________________________________________
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Eje III: ____________________________________________________________________
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Eje IV: ____________________________________________________________________
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Eje V: ____________________________________________________________________
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IX. PRONÓSTICO
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X. RECOMENDACIONES
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*SE DEBE EMITIR INFORME PSICOLÓGICO CUANDO EL PACIENTE CUENTE CON

INSTRUMENTOS EVALUADOS. EL NÚMERO DE INFORMES QUE EL SUPERVISOR
REVISE EN EL CENTRO DE PRÁCTICAS, DEBERÁ CORRESPONDER AL NÚMERO DE
INFORMES SOLICITADOS POR EL ASESOR Y ACORDE A LAS DIRECTIVAS DADAS POR
LA COORDINACIÒN DE PRÀCTICAS PRE PROFESIONALES.