N°

FICHA CLÍNICA Fecha de

Admisión
CENTRO DE ATENCIÓN PSICOLÓGICA
CALBUCO

ANTECEDENTES PERSONALES:

Nombre completo: __________________________________________________________

RUT: ____________________ Edad: _________ Fecha de Nacimiento: ______________
Estado civil: __________________ Previsión: _______________ Email:
_______________
Escolaridad: _____________________Ocupación:________________________________
Lugar de Trabajo y/o Estudio: ________________________________________________
Dirección: __________________________________________ Fono: __________________
Familiar de de Contacto: ____________________________________________________
GENOGRAMA
Profesional FAMILIAR:
Responsable: _____________________________________________________
Fono contacto: _______________________

l. MOTIVO DE CONSULTA:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

lll. DEFINICIÓN DEL PROBLEMA:

 EVOLUCIÓN:______________________________________________________________________________________
 N°

FICHA CLÍNICA Fecha de

Admisión
CENTRO DE ATENCIÓN PSICOLÓGICA
CALBUCO

__________________________________________________________________________________________________
__________________________________________________________________________________________________

 CAUSAS:__________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

 ACCIONES REALIZADAS EN BUSCA DE SOLUCIÓN:

____________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

 IMPLICACIONES: (a nivel familiar, social, académico, etc.):

__________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

lV. ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:

 FAMILIOGRAMA:

MIEMBRO PARENTESCO EDAD ESCOLARIDAD OCUPACIÓN

 VINCULOS AFECTIVOS CONFLICTIVOS Y REDES DE COMUNICACIÓN:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

V. HISTORIA PERSONAL:

 INFANCIA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

 ADOLESCENCIA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
 N°

FICHA CLÍNICA Fecha de

Admisión
CENTRO DE ATENCIÓN PSICOLÓGICA
CALBUCO

__________________________________________________________________________________________________

VI. HISTORIA ESCOLAR:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

VII. OBSERVACIONES: (descripción física, lenguaje no verbal, actitud, etc.)

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

VIII. DIMENSIONES:

 COMPORTAMENTAL: ______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________
 AFECTIVA: ________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________
 SOMATICA:________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
 COGNITIVA:_______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
 SOCIAL: __________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

IX. PRUEBA Y ANÁLISIS DE RESULTADOS:

 PERSONALIDAD:___________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
 INTELIGENCIA: ____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
 HABILIDADES:_____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
 N°

FICHA CLÍNICA Fecha de

Admisión
CENTRO DE ATENCIÓN PSICOLÓGICA
CALBUCO

__________________________________________________________________________________________________
 OTRAS:___________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

X. IMPRESIÓN DIAGNÓSTICA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

XI. TRATAMIENTO A SEGUIR:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
EVOLUCIÓN

Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripción: _______________________________________________________________________________________
__________________________________________________________________________________________________

Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripción: _______________________________________________________________________________________
__________________________________________________________________________________________________

Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripción: _______________________________________________________________________________________
__________________________________________________________________________________________________

Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripción: _______________________________________________________________________________________
__________________________________________________________________________________________________

Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
 N°

FICHA CLÍNICA Fecha de

Admisión
CENTRO DE ATENCIÓN PSICOLÓGICA
CALBUCO

Descripción: _______________________________________________________________________________________
__________________________________________________________________________________________________

Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripción: _______________________________________________________________________________________
__________________________________________________________________________________________________

EVALUACIÓN REALIZADA POR: ____________________________________

 CONTROL DE CAMBIOS

FECHA DE
VERSIÓN DESCRIPCIÓN DE CAMBIOS REALIZADOS
APROBACIÓN
- Inclusión de Control de Cambios.
02 Abril 15 de 2009 - Inclusión de página y otros ajustes en el
encabezado.

03 Abril 23 de 2009 - Inclusión de Documento de identidad.