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Fecha _______/________/________

RBD 09750-0

PASAJE SATURNO 03955

FONO:27800198. LO ESPEJO

REGISTRO DE ENTREVISTA

IDENTIFICACION
La entrevista corresponde a:
Apoderado ______ o Estudiante ______ Ambos ______

Estudiante : Curso
:___________
Apoderado: ___________________________________________ Fono contacto :_____________
Domicilio : _______________________________________________________________________

OTROS ANTECEDENTES
Consultorio : _____________________________________________ Sector :_______________
Tratamiento Si No Indique :_______________________________________________________
Institución Si No Indicar (OPD, FAE, PPF, Etc)_________________________________________
Repitente : Si No Curso : _______________________________
Derivación : Si No Indicar :______________________________________________
Profesionales que entrevistan
Psicopedagoga___ Ed. Diferencial___ Psicólogo___ Fonoaudióloga___ Coordinadora ____
Trabajador Social___ Otro____________________________________

MOTIVO DE LA ENTREVISTA :
Pupilo victima acoso escolar __ Pupilo victimario acoso escolar__ Acoso escolar cruzado___
Problemas académicos __ Conflicto con docente___ Inasistencias reiteradas____
Otro __ Indicar ______________________________________________________________

DESARROLLO DE LA ENTREVISTA:
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ACUERDO Y/O COMPROMISO :


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Entrevistado Entrevistado Profesional Profesional

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