FICHA PSICOLÓGICA

FECHA: …………………

I. DATOS DE FILIACION:
Apellidos y nombres:…………………………………………………………..………….……………………………………….
Edad: ….…… Sexo: …….. Fecha de Nac.: …/…../….. Lugar de Nac:….…..…….………………….
Lugar entre hermanos: ……/…… Grado de instrucción:……………………………………….
Ocupación:……………………….… Estado Civil:…………… N° hijos:……………………
Religión:…………….… Dirección:………………………….………….……………………………………………..…………
Teléfono: ………………………………. Mail:……………………………………….…………
Lugar de evaluación: …………………………………………………………………………………………………..…………
Informante: ……………………………………………………………..……………………………………………………………
Evaluador: ……………………………………………………….………………………………………………………….…………
Derivado por:…………………………………………………………………..………………………………………….…………

II. MOTIVO DE CONSULTA

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III. PROBLEMA ACTUAL

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IV. ANAMENESIS (ANTECEDENTES RELEVANTES)

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V. OBSERVACIONES GENERALES
Físicas
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Conductuales
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VI. MEDIO EMPLEADOS 1. Observación 2. Entrevista

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VII. APRECIACIÓN DEL PROBLEMA

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VIII. DIAGNOSTICO PRESUNTIVO
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IX. RECOMENDACIONES Y/O TRATAMIENTO

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