HISTORIA CLINICA PSICOLOGICA

1.

DATOS DE IDENTIFICACION

NOMBRE DEL CONSULTANTE:

DIRECCIN:
TELFONO:
OCUPACIN:
ENTIDAD:

EDAD:

NOMBRE DEL ACUDIENTE:

PARENTALIDAD:
OCUPACIN:

EDAD:

2.

HISTORIA CLINICA

I.
MOTIVO DE CONSULTA
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II.
REMISIN
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III.

ACONTECIMIENTOS Y EXPERIENCIAS SIGNIFICATIVAS EN LA HISTORIA

INDIVIDUAL, FAMILIAR Y/O CONTEXTUAL
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IV.
TRATAMIENTOS MDICOS, PSICOLGICOS O PSIQUITRICOS.
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V.

GENOGRAMA

VI.
DESCRIPCIN DEL PROBLEMA POR EL CONSULTANTE
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VII.
DIAGNOSTICO (CIE -10)
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VIII.
COMPRENSIONES DEL CASO
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IX.
OBJETIVO(S) INTERVENTIVO(S)
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X.
ESTRATEGIAS GENERALES DE INTERVENCIN
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XI.

NUMERO DE SESIONES
TIEMPO DEL TRATAMIENTO
PSICOTERAPUTICO

FIRMA PROFESIONAL

FIRMA DEL CONSULTANTE