FICHA DE ATENCIÓN PSICOLÓGICA AL ESTUDIANTE

Fecha: ………………………………….
I. DATOS DE FILIACIÓN
Nombre y Apellidos: ……………………………………………………………………………………………………. Edad: ……………………………...................
Fecha de Nacimiento: …………………………………………………………………………………………………. Grado y Sección: ………..……………………
Número de Hermanos: ……………………………………………………………………………………………….. Lugar en la Familia: ………………………..
Domicilio: ……………………………………………………………………………………………………………………. Lugar de Procedencia: ……………..…….
Teléfono/Celular: ……………………………………………………….....…………………………………………………………………………………………….………..
Nombre de la Mamá: …………………………………………..... Grado de instrucción: …..….................………….. Ocupación: …………………..
Nombre del Papá: …………………………………………………… Grado de instrucción: ……………….………………... Ocupación: …………………..

II. MOTIVO DE ATENCIÓN O DERIVACIÓN

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DESCRIPCIÓN DEL PROBLEMA
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III. ÁREAS A EVALUAR
CONTEXTO FAMILIAR
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CONTEXTO ESCOLAR
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ÁMBITO SOCIAL
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IV. COMPROMISO
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V. APOYO A RECIBIR
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