FICHA DE ATENCION PSICOLGICA

I.- DATOS DE FILIACION

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Nombre y Apellido
Edad
Estado Civil
N de Hijos
Grado de Instruccin
Ocupacin
N de Hermanos
Posicin que Ocupa
Domicilio
Religin

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II.- MOTIVO DE CONSULTA

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III.- SINTOMATOLOGIA
Cognitivo

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Afectivo

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Fisiolgico

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Conductual

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IV.- HISTORIA PERSONAL

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V.- INSTRUMENTOS APLICADOS
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VI.- RESULTADOS
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VII.- DIAGNOSTICO
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VIII.- PRONSTICO
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IX.- PLAN TERAPEUTICO Y RECOMENDACIONES
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X.- EVOLUCION
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