LUIS CARLOS GALÁN SARMIENTO

PSICOLOGÍA
SEGUIMIENTO Y ACOMPAÑAMIENTO ESCOLAR

Fecha: Departamento:
Nombre del estudiante: Grado:
Fecha de Nacimiento: Edad:
Barrio: Teléfono:

Nombre del padre: ___________________________________ Ocupación: ________________________

Nombre de la madre: __________________________________ Ocupación: ________________________

Nombre del estudiante: ________________________________ Ocupación: ________________________

Personas con quien vive y permanece:

Vive con: _____________________________________________________

Permanece con: ________________________________________________

Citación # _1__

1.Persona que remite: _____________________________________________

2.Motivo de remisión

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3. Descripción de la situación:
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4.Acuerdos y recomendaciones por parte del profesional:

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5.Compromisos por parte de padres:

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6.Compromisos por parte del estudiante:

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Firma de acudiente: ______________________________ C.C: __________________________

Consentimiento estudiante: _________________________