HISTORIA PSICOLOGICA

A. DATOS GENERALES:

Nombres Y Apellidos:
Edad:
Sexo:
Fecha De Nacimiento:
Lugar De Nacimiento:
Institución Educativa:
Escolaridad:
Estado Civil:
Dirección:
Celular:
Religión:
Nº Hermanos: Lugar que Ocupa:
Referencia:
Fecha De Atención:

B. DATOS FAMILIARES:

Apellidos y Nombres Parentesc Edad Grado De Ocupación Convivencia

o Instrucción

C. MOTIVO DE ATENCIÒN:
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D. ENFERMEDAD O PROBLEMA ACTUAL:
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E. ANTECEDENTES:
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F. ACTITUDES DE PADRES O FAMILIARES:

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G. OBSERVACION DE LA CONDUCTA Y ACTITUDES DEL ESTUDIANTE:

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H. DX:
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I. RECOMENDACIONES:
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PS. GISELLA SUGEY CRUZADO CARRANZA.

CPP.31694