Atención Psicológica Integral para el Cuidado y Prevención de la Salud

Programa de Tratamiento

Ficha de Identificación.

Nombre: _________________________________________________________________________
Apellido Paterno Apellido Materno Nombre(s)

Dirección: ________________________________________________________________________
Calle Número Colonia

Delegación: ___________________ C.P.______________ Sexo: (M) (F) Edad: ________

Estado Civil: __________________ Tel. Local: _______________ E-mail: _______________

Tel. Celular: ___________________ Tel Recados: _____________ con ____________________

Dx. Médico: _______________________________________________________________________

Dx. Psicológico: ____________________________________________________________________

Objetivo del Tratamiento: ____________________________________________________________

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Modalidad de Tratamiento: ___________________________________________________________

Áreas de Trabajo: __________________________________________________________________

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Conducta Objetivo.

a) Excesos cognitivo-conductuales: ____________________________________________________

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b) Déficits cognitivo-conductuales: _____________________________________________________

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c) Recursos y destrezas cognitivo-conductuales: _________________________________________

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Poza Rica No. 8 Col. San Jerónimo Aculco C.P. 10400 Del. Magdalena Contreras. Tel. 55-68-50-02
Atención Psicológica Integral para el Cuidado y Prevención de la Salud

Métodos de Recolección de Información

a) Manifestaciones abiertas de la conducta del paciente: ___________________________________

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b) Manifestaciones cognoscitivas de la conducta: _________________________________________

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c) Conductas que el paciente monitoreará y registrará: _____________________________________

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d) Indicadores fisiológicos ____________________________________________________________

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e) Conductas que el personal médico monitoreará y registrará: _______________________________

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Análisis Funcional de la Conducta

a) Eventos (manifiestos/encubiertos) que preceden a la conducta: ____________________________

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b) Eventos (manifiestos/encubiertos) que siguen a la conducta: ______________________________

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c) Ganancias secundarias por emitir la conducta: __________________________________________

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Poza Rica No. 8 Col. San Jerónimo Aculco C.P. 10400 Del. Magdalena Contreras. Tel. 55-68-50-02
Atención Psicológica Integral para el Cuidado y Prevención de la Salud

Motivación para el Cambio

a) Qué será diferente cuándo el problema cambie?

Paciente: _________________________________________________________________________
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Familia: __________________________________________________________________________
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Otras áreas: _______________________________________________________________________

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b) Eventos reforzadores potenciales que apoyen al cambio de la conducta:

-Positivos _________________________________________________________________________
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-Negativos________________________________________________________________________
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-Neutros: _________________________________________________________________________
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Factores que Mantienen el Problema

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Poza Rica No. 8 Col. San Jerónimo Aculco C.P. 10400 Del. Magdalena Contreras. Tel. 55-68-50-02
Atención Psicológica Integral para el Cuidado y Prevención de la Salud

Programa de Intervención

a) Objetivo General del Tratamiento: ___________________________________________________

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b) Objetivos Específicos y Actividades por Área:

Amistades________________________________________________________________________
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Laborales_________________________________________________________________________
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Familiares________________________________________________________________________
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Académicas_______________________________________________________________________
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Sexuales_________________________________________________________________________
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Salud____________________________________________________________________________
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Evaluación del Programa de Intervención.

a) Resultados Obtenidos: ____________________________________________________________

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b) Satisfacción al tratamiento: _________________________________________________________

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Terapeuta Responsable: _____________________________________________________________

Poza Rica No. 8 Col. San Jerónimo Aculco C.P. 10400 Del. Magdalena Contreras. Tel. 55-68-50-02