ENTREVISTA PSICOLÓGICA

Fecha: _____

N° de Historia: ____

DATOS DE IDENTIFICACIÓN:

Nombre y Apellidos: _________________________________ Edad: _______

Lugar y Fecha de Nacimiento: __________________________ C.I:_________

Estado Civil: ___________ Religión: ____________ Sexo: _____ Dirección:

_____________ Grado de Instrucción: ____________________ Teléfono: _____________

Cargo Al que Aspira:

II. EXSAMEN MENTAL:

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III. ANTECEDENTES FAMILIARES:

Dinámica Familiar:

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Antecedentes Médicos Familiares:

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Antecedentes Psicológicos Familiares:

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 ENTREVISTA PSICOLÓGICA

IV. ANTECEDENTES PERSONALES:

Prenatales:

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Para natales:

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Post natales:

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Antecedentes Patológicos:

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Enfermedades Anteriores:

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Psicológicos:

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V. AREAS DE EXPLORACION:

Psicosociales:_________________________________________________________________________
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Escolaridad:__________________________________________________________________________
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Participación en grupos de interés:

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Hábitos psicobiologicos:
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Aspiraciones:_________________________________________________________________________
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Fortalezas:___________________________________________________________________________
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Debilidades:__________________________________________________________________________
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INSTRUMENTOS HALLAZGOS

FIGURA HUMANA

WARTEGG

BENDER

16 pf
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VI Observaciones
Generales :___________________________________________________________________________
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Realizado por:_________________________