HISTORIA CLÍNICA PSICOLÓGICA

Fecha primera entrevista: Nº Historia Clinica:

1.- DATOS PERSONALES

NOMBRE DEL MENOR:

DNI: EDAD:
DOMICILIO:
NACIONALIDAD: OBRA SOCIAL:

NOMBRE DEL ADULTO CONSULTANTE:

PARENTALIDAD: EDAD:
DNI: OCUPACIÓN:
DOMICILIO:
NACIONALIDAD: OBRA SOCIAL:
NÚMERO DE CELULAR: NÚMERO DE TELÉFONO:
EMAIL: CONSENTIMIENTO:
NIVEL DE ESTUDIOS: ESTADO CIVIL:

NOMBRE DEL ADULTO CONSULTANTE:

PARENTALIDAD: EDAD:
DNI: OCUPACIÓN:
DOMICILIO:
NACIONALIDAD: OBRA SOCIAL:
NÚMERO DE CELULAR: NÚMERO DE TELÉFONO:
EMAIL: CONSENTIMIENTO:
NIVEL DE ESTUDIOS: ESTADO CIVIL:

2.- HISTORIA CLÍNICA

I. MOTIVO DE CONSULTA:

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 II. REMISIÓN

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III. HISTORIA DEL MENOR

A) EMBARAZO

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B) PARTO

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 C) ALIMENTACIÓN

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D) CHUPETE

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E) LENGUAJE

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F) MOTRICIDAD

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 G) DENTICIÓN

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H) SUEÑO

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I) CONTROL DE ESF´ÍNTERES

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J) JUEGO

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K) SEXUALIDAD

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 L) ENFERMEDADES

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M)ESCOLARIDAD

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N) RELACIONES AFECTIVAS

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 IV. HISTORIA FAMILIAR
A) HISTORIA DE LA PAREJA

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 B) COMPOSICIÓN FAMILIAR Y GENOGRAMA

C) IDEOLOGÍA DE CRIANZA

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D) PROYECTOS DE LA FAMILIA

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3.- EVALUACIÓN

I. PRUEBAS ADMINISTRADAS

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II. RESULTADO DE LAS PRUEBAS ADMINISTRADAS

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4.- DIAGNÓSTICO

I. DIAGNÓSTICO (DSM Y/OCIE)

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II. DIAGNÓSTICO/COMPRENSIÓN PSICODINÁMICA

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4.- INDICACIONES TERAPEUTICAS

I. DESCRIPCIÓN DE INDICACIONES

Psicoterapia individual No psicoterapia

Psicoterapia vincular Derivación otro profesional
Psicoterapia familiar Otras

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I. OBJETIVOS DE LA INTERVENCIÓN características del

encuadre, actitud terapéutica y estilo de intervención
planificadas para el paciente.

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II. FOCOS DE INTERVENCIÓN

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III. TIEMPO DE TRATAMIENTO

Número de sesiones semanales

Estimación de duración

FIRMA Y SELLO DEL PROFESIONAL A CARGO:

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5.- SEGUIMIENTO

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