REGISTRO DE ENTREVISTA AL PADRE DE FAMILIA

Profesor(a): __________________________________________________________________________________________________
Fecha: _____/____/_________

NOMBRE Y APELLIDOS DEL PADRE DE FAMILIA NOMBRE Y APELLIDOS DEL ALUMNO(A) GRADO

MOTIVO DE LA ENTREVISTA

____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
___________________ .

DESARROLLO DE LA ENTREVISTA
(anotar brevemente todo aquello que se considere importante incluido el lenguaje no verbal)

____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
__________________________.

CONCLUSIÓN
(tomar nota de acuerdos, recomendaciones, derivaciones, asuntos pendientes y/o próximo encuentro, etc.)

____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________.

___________________________________________ _______________________________
FIRMA DEL PADRE MADRE O APODERADO. FIRMA DEL PROFESOR(A)
 REGISTRO DE ENTREVISTA AL ALUMNO

Profesor(a): _______________________________________________________________
Fecha: _____/____/_________

NOMBRE Y APELLIDOS DE LA ALUMNA EDAD GRADO/AÑO

MOTIVO DE LA ENTREVISTA

____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
___________________ .

DESARROLLO DE LA ENTREVISTA
(anotar brevemente todo aquello que se considere importante incluido el lenguaje no verbal)

____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
__________________________.

CONCLUSIÓN
(tomar nota de acuerdos, recomendaciones, asuntos pendientes y/o próximo encuentro)

____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________.
 _______________________________
FIRMA DEL PROFESOR(A)

COMPROMISO ENTRE EL PADRE DE FAMILIA Y EL COLEGIO

Yo, _____________________________________padre/madre de la alumna______________________________________

del _______________ grado/año de ____________________________de la I.E Santa Paula School, luego de
haber dialogado y escuchado las recomendaciones respecto a la situación de mi menor
hijo(a), me comprometo a:

1. _________________________________________________________________________________________________________
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
4. _________________________________________________________________________________________________________
5. _________________________________________________________________________________________________________

____________________________ __________________________
TUTOR (A) PADRE DE FAMILIA

Arequipa, _________ de ___________________________del ________________

 FICHA DE DERIVACIÓN DE CASOS AL SERVICIO DE PSICOLOGÍA

ALUMNA: ___________________________________________________________________ GRADO/AÑ O_______________________________

PROFESOR(A):
________________________________________________________________________________________________________________

FECHA: _____/______/__________

1. MOTIVO DE LA DERIVACIÓ N.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________ .

2. NÚ MERO DE DERIVACIONES.

Primera ( ) Segunda ( ) Tercera ( )

3. ANTECEDENTES (familiares, escolares, del desarrollo, etc.)

_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________ .

4. CLASIFICACIÓ N DEL PROBLEMA

Rendimiento académico Dificultades para aprender

Conducta Comunicació n familiar
Estado emocional Autoestima
Otro (especifique)

___________________________________________

___________________________________________________________
 NOMBRE Y FIRMA DEL PROFESOR(A) QUE DERIVA EL CASO

Los datos contenidos en esta ficha son confidenciales.