l.

DATOS PERSONALES

No. Historia:____________ Lugar y Fecha:________________________

Nombres:________________________________________
Apellidos:________________________________________
Documento de identidad: No. ____________________
Edad:_______ Sexo:____ Estado Civil:___ Hijos_____ Edades y Sexo_______________________
Lugar y fecha de Nacimiento:_________________________________ Nivel Académico:________
Religión: ____________
Dirección actual:________________________________________________________________________
Teléfono: _____________

ll. MOTIVO DE CONSULTA:

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lll. DEFINICIÓN DEL PROBLEMA:

 EVOLUCIÓN:______________________________________________________________________________________
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 CAUSAS:__________________________________________________________________________________________
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 ACCIONES REALIZADAS EN BUSCA DE SOLUCIÓN:

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 IMPLICACIONES: (a nivel familiar, social, académico, etc.):

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lV. ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:

 FAMILIOGRAMA:

MIEMBRO PARENTESCO EDAD ESCOLARIDAD OCUPACIÓN

 HISTORIA PSICOLOGICA CLÍNICA

 RELACIÓN MATERNA, PATERNA, FILIAL, VINCULOS AFECTIVOS CONFLICTIVOS Y REDES DE

COMUNICACIÓN:
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V. HISTORIA PERSONAL:

 INFANCIA:
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 ADOLESCENCIA:
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VI. RELACIÓN DE PAREJA Y/O HISTORIA CONYUGAL:

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VII. OBSERVACIONES: (descripción física, lenguaje no verbal, actitud, hábitos, etc.)

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VIII. DIMENSIONES:

 COMPORTAMENTAL: ______________________________________________________________________________
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 AFECTIVA: ________________________________________________________________________________________
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 SOMATICA:________________________________________________________________________________________
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 COGNITIVA:_______________________________________________________________________________________
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Elaborado por Lcda. María de Lourdes Linares- Psicóloga Especialista

 HISTORIA PSICOLOGICA CLÍNICA

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 SOCIAL: __________________________________________________________________________________________
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IX. INSTRUMENTOS PSICOLÓGICOS UTILIZADOS:

PROYECTIVOS:
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PSICOMETRICOS:
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ANÁLISIS E INTERPRETACIÓN DE RESULTADOS:

EXAMEN MENTAL: _____________________________________________________________________________________

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 PERSONALIDAD:___________________________________________________________________________________
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 INTELIGENCIA: ____________________________________________________________________________________
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 HABILIDADES:_____________________________________________________________________________________
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 OTRAS:___________________________________________________________________________________________
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X. IMPRESIÓN DIAGNÓSTICA:
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XI. TRATAMIENTO A SEGUIR:

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XII. RECOMENDACIONES:
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Elaborado por Lcda. María de Lourdes Linares- Psicóloga Especialista

 HISTORIA PSICOLOGICA CLÍNICA

EVOLUCIÓN

Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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EVALUACIÓN REALIZADA POR: ____________________________________

Elaborado por Lcda. María de Lourdes Linares- Psicóloga Especialista