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HISTORIA CLINICA PSICOLOGICA

Fecha de la entrevista: __________________________________________________________________________


Lugar de la entrevista:
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1. generales.

Nombre:
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Sexo: _____________________________________ edad: _______________________________________________
Fecha Nacimiento. :______________________________________________________________________________
Lugar de nacimiento: ____________________________________________________________________________
Religión:
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Estado civil:
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Escolaridad: _____________________________________________________________________________________
Ocupación: _____________________________________________________________________________________
Dirección y teléfono particular:
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2. Descripción física del paciente:


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3. Motivo de estudio/consulta:
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4. Situación actual
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5. Constelación familiar (historia familiar):

Nombre Parentesco Escolaridad Tipo de relación

Rio Yaqui 2234, local D, Col. Revolución


Tel. 686-24-30 , cel consultorio (664) 776-85- 44Cel. Intervención en crisis 24/7 (664) 114 – 0586
6. Historia personal y recuerdos tempranos:
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7. Salud:
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8. Escolaridad (vida escolar):


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9. Record de trabajo (vida laboral):


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10. Diversiones e intereses:


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11. Ajustes sociales:


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12. Desarrollo sexual (vida sexual):


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Rio Yaqui 2234, local D, Col. Revolución


Tel. 686-24-30 , cel consultorio (664) 776-85- 44Cel. Intervención en crisis 24/7 (664) 114 – 0586
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13. Datos maritales y familiares (vida conyugal, novio, pareja...)


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14.Descripción de si mismo:
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15. Exploración psicológica: (áreas exclusivas del psicólogo)


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16. Pruebas psicológicas aplicadas:


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17. Diagnóstico:
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18.Pronóstico:
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19. Tratamiento:
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Rio Yaqui 2234, local D, Col. Revolución


Tel. 686-24-30 , cel consultorio (664) 776-85- 44Cel. Intervención en crisis 24/7 (664) 114 – 0586