FICHA CLINICA Fecha:________________

Antecedentes Terapeuta:______________________
Nombre Paciente:___________________________________________________Edad:____________________
Fecha Nacimiento:___________________________Escolaridad:_________Colegio:______________________
Teléfonos y correos electrónico:________________________________________________________________
Grupo Familiar

Nombre Edad Actividad Parentesco Vive con el niño/a?

¿Porque consultan? (registrar textual), ¿Quién deriva?:

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Motivo de consulta explícito e implícito (desde los padres y desde el niño/adolescente):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Historia del motivo de consulta (cuando partió, como ha sido abordado, porqué consultan ahora):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Síntomas asociados al motivo de consulta:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Explicaciones en relación al motivo de consulta (de los padres y del niño/adolescente):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Diagnósticos y tratamientos anteriores:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Salud mental familiar (antecedentes psicológicos y psiquiátricos, diagnósticos y tratamientos):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Historia psicosocial y familiar (genograma, relaciones familiares, antecedentes educacionales y sociales,
consumos etc):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Examen mental (considerar a los padres y al niño/adolescente, apariencia, actitud, orientación, cogniciones,
afecto, juicio):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Evaluación de riesgos (suicida, daño a otros, maltrato, abuso, ausencia de red de apoyo):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Comentarios sobre los riesgos observados (acuerdos, indicaciones, manejo, coordinación con otros
profesionales):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Fortalezas en el niño/adolescente y su familia:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Diagnóstico descriptivo:
Eje I (trastornos clínicos y otros problemas que pueden ser objeto de atención clínica):
________________________________________________________________________________________
Eje II (trastornos de la personalidad y retraso mental):
________________________________________________________________________________________
Eje III (enfermedades médicas):
________________________________________________________________________________________
Eje IV (problemas psicosociales y ambientales):
_________________________________________________________________________________________
Eje V (evaluación de la actividad glogal EEAG (0 a 100):
__________________________________________________________________________________________
Justificación del diagnóstico:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Diagnóstico comprensivo (considerar aspectos individuales, familiares, relacionales y del desarrollo):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Plan de tratamiento (objetivos, foco terapéutico, prioridades, derivaciones):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Factores de adherencia y deserción (considerar inicio de tratamiento, mantención y cierre, identificando
posibles dificultades en las tres etapas):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Otras observaciones y comentarios:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________