FICHA DE DERIVACION

Derivado por el tutor(a):_______________________________________________

Tenga a bien indicar los MOTIVOS por los que el alumno(a), debe ser derivado al
Departamento Psicológico.

 Alumno : ____________________________________________________
 Grado : ____________________________________________________
 Fecha : ____________________________________________________

MOTIVO DE DERIVACION (describir tal como se observa la conducta, en forma

detallada):

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SUGERENCIAS:

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Firma del tutor(a)………………………………………………..