HISTORIA CLÍNICA DE PSICOLOGÍA

DATOS PERSONALES

Fecha: _____________
Nombres:_______________________________________ Apellidos:______________________________
Documento de identidad: T.I.___ C.C.___ No. _______________________________
Edad:______________ Sexo:__________ Estado Civil:______________
Lugar y fecha de Nacimiento:___________________________________________________________
Carrera:_______________________ Nivel:________
Dirección actual:________________________________________________________________________
Teléfono: _____________
Dirección de la Familia: ___________________________________ Ciudad:____________________
Teléfono: _______________

Ha recibido algún tipo de tratamiento psicológico o psiquiátrico:

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MOTIVO DE CONSULTA:
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DEFINICIÓN DEL PROBLEMA:

 EVOLUCIÓN:______________________________________________________________________________________
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 CAUSAS:__________________________________________________________________________________________
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 IMPLICACIONES: (a nivel familiar, social, académico, etc.): _________________________________________

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ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:

MIEMBRO PARENTESCO EDAD ESCOLARIDAD OCUPACIÓN

Yuceth Yohana Daza Cuello

Psicóloga – Especialista en gerencia del talento humano
Registro N° 118763
Celu: 3147509348
 HISTORIA CLÍNICA DE PSICOLOGÍA

 VINCULOS AFECTIVOS CONFLICTIVOS Y REDES DE COMUNICACIÓN:

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HISTORIA PERSONAL:

 INFANCIA:
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 ADOLESCENCIA:
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HISTORIA ESCOLAR:
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OBSERVACIONES: (descripción física, lenguaje no verbal, actitud, etc.)
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DIMENSIONES:

 COMPORTAMENTAL: ______________________________________________________________________________
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 AFECTIVA: ________________________________________________________________________________________
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 SOMATICA:________________________________________________________________________________________
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 COGNITIVA:_______________________________________________________________________________________
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 SOCIAL: __________________________________________________________________________________________
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IMPRESIÓN DIAGNÓSTICA:
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Yuceth Yohana Daza Cuello
Psicóloga – Especialista en gerencia del talento humano
Registro N° 118763
Celu: 3147509348
 HISTORIA CLÍNICA DE PSICOLOGÍA

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FIRMA: ____________________________________

Yuceth Yohana Daza Cuello

Psicóloga – Especialista en gerencia del talento humano
Registro N° 118763
Celu: 3147509348
 Yuceth Yohana Daza Cuello
Psicóloga – Especialista en gerencia del talento humano
Registro N° 118763
Celu: 3147509348