Wendy Lizeth González Castillo

Psicoterapia breve y de emergencia

LPSMM8

I. FICHA DE IDENTIFICACIÓN
Nombre: __________________________________________________________________
Fecha de nacimiento: ___________ Edad: ______ Ocupación: _______________________
Lugar de nacimiento: ________________________________________________________
Escolaridad: _________________________ Religión: ______________________________
Domicilio: _________________________________________________________________
Estado civil: _________________ Teléfono trabajo: ________________________________
Teléfono (Casa/Celular): _____________________________/________________________
MOTIVO DE CONSULTA

II. CONTENIDO MANIFIESTO Y LATENTE

III. APARIENCIA GENERAL, PORTE Y ACTITUD DEL PACIENTE

IV. HISTORIA PERSONAL

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 Wendy Lizeth González Castillo
Psicoterapia breve y de emergencia
LPSMM8

V. HISTORIA ESCOLAR

VI. HISTORIA DE SALUD

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 Wendy Lizeth González Castillo
Psicoterapia breve y de emergencia
LPSMM8

VII. HISTORIA FAMILIAR

 DEL PADRE:
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 DE LA MADRE:
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 HERMANAS:
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 HERMANOS
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 ABUELOS PATERNOS:
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 ABUELOS MATERNOS:
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 Wendy Lizeth González Castillo
Psicoterapia breve y de emergencia
LPSMM8

VIII. FAMILIOGRAMA

IX. SOCIAL

X. ACTITUD ANTE LA ENTREVISTA

XI. DESARROLLO DINÁMICO Y ESTRUCTURAL

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 Wendy Lizeth González Castillo
Psicoterapia breve y de emergencia
LPSMM8

XII. OBSERVACIONES