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EXPEDIENTE PSICOLOGICO

I. DATOS GENERALES
DATOS PERSONALES
NOMBRE: ___________________________________________________________________________________
EDAD: ________ AÑOS FECHA DE NACIMIENTO: __________ / ______________________ / __________
SEXO: _____________________ RAZA: _______________________ RELIGIÓN: _______________________

LUGAR DE NACIMIENTO: _______________________ LUGAR DE RESIDENCIA: __________________________


CURSO: __________________ SECCIÓN: ____________________
REALIZA ALGUNA ACTIVIDAD EXTRA ESCOLAR: _________ ACTIVIDAD: _____________________________
MOTIVO DE LA CITA: __________________________________________________________________________
FECHA DE ATENCIÓN: __________ / ______________________ / __________
DATOS FAMILIARES
NOMBRE DEL PADRE: _________________________________________________________________________
NOMBRE DE LA MADRE: _______________________________________________________________________
ESTADO CIVIL DE LOS PADRES: ____________________________________
CON QUIEN VIVE EL ALUMNO: ____________________________________
DIRECCION: _________________________________________________________________________________
TELEFONO: ________________________________
CASA PROPIA O ALQUILADA: ____________________

II. ANTECEDENTES
CONDICIONES DEL EMBARAZO: __________________________________________________________________
1era INFANCIA: _______________________________________________________________________________
ABUSO Y VIOLENCIA: __________________________________________________________________________

III. HISTORIA CLINICA


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IV. PRINCIPALES SINTOMAS


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V. TECNICAS TERAPEUTICAS
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VI. PLAN TERAPEUTICO


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VII. DIAGNOSTICO
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VIII. RECOMENDACIONES
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IX. PLAN DE SEGUIMIENTO


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