REPORTE CONSEJERÌA TANATOLÒGICA

FICHA DE IDENTIFICACIÓN FECHA _____/_____/_____

NOMBRE: ______________________________________________________________________ EDAD: ___________________ SEXO: _____________________________
ESTADO CIVIL: _______________________________ RELIGION:___________________________________ ESCOLARIDAD:_____________________________________ OCUPACIÓN:
___________________________________________ NACIONALIDAD:________________________ RESIDENCIA:___________________________________ No. DE HIJOS: __________________
No. DE EMBARAZOS: ___________________

MOTIVO DE CONSULTA:
________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________

ANTECEDENTES
TIPO DE TERAPIAS QUE HA TOMADO ANTERIORMENTE

________________________________________________________________________________________________________________________________________________________

TIEMPO DE LA TERAPIA QUE TOMÒ ANTERIORMENTE:

________________________________________________________________________________________________________________________________________________________

MEDICAMENTOS QUE TOMA:

________________________________________________________________________________________________________________________________________________________

ESCENA FUNDANTE
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________

MITO FUNDANTE
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________

PALABRAS O FRASES CLAVES O DE INSISTENCIAS

________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
 ESTRUCTURACIÒN DE EJES TEMÀTICOS:
SESION 1 SESIÒN 2 SESIÒN 3 SESIÒN 4 SESIÒN 5 SESIÒN 6 SESIÒN 7 SESIÒN 8 SESIÒN 9 SESIÒN 10

MÒVILES Y BARRERAS:
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________

ALTERNATIVAS PROPUESTAS

________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________

OBSERVACIÒN E HIPÒTESIS

 Lo que le hace llorar es:

____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
 Lo que le hace enojar es:
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
 Su reacción ante esta técnica es
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

CONCLUSIÒN GENERAL:

NOMBRE Y FIRMA
_________________________________________________