FICHA DE ATENCIÓN PSICOLÓGICA Fecha: ______________
1. Dato Datoss Gene Genera rale less Nombre de el/la estudiante:
_____________________________________ ________________________________________________________ ____________________ _
Fecha de Nac.:___________________ Nac.:___________________ Dirección:
Edad: _________ Grado y Sección: _______________
_____________________________________ ____________________________________________ _______ Teléfono: ___________________
2. Dato Datoss Fam Famil ilia iare ress adre: ___________________ ___________________________ ________ Edad_____ !cu"ación____________ !cu"ación____________ E.#i$il_______ %adre: ___________________________ ___________________________ Edad_____ !cu"ación____________ !cu"ación____________ E.#i$il_______ &ermanos: ___________________ ______________________________________ ______________________________________ _____________________________________ __________________ !tros Familiares y/o a"oderados: _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________
. Din! Din!mi mi"a "a Fam Famil ilia iarr __________________________________________________________ _______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________
#. Hist Histor oria ia Pers Person onal al __________________________________________________________ _______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________ _______________________________________ ____________________ ______________________________________ _______________________________________ ____________________________ ________
$. E%al&a"i'n( E%al&a"i'n(Se)&i Se)&imien miento to Psi"ol')i Psi"ol')i"o "o Fe"*a(+oti%o ,e Cons<a
Ante"e,entes Ante"e,entes ,el Pro-lema(Dia)n'sti"o Pro-lema(Dia)n'sti"o
e"omen,a"iones e"omen,a"iones
Fe"*a(+oti%o ,e Cons<a
Ante"e,entes ,el Pro-lema(Dia)n'sti"o
e"omen,a"iones
