HISTORIA CLÍNICA No.____________________

1. DATOS DE IDENTIFICACIÓN

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Apellidos: _______________________________________________________________

No. Documento: _______________________ de: _______________________________

Fecha y lugar de nacimiento: ________________________________________________

Escolaridad: _____________________________________________________________

Ocupación: ______________________________________________________________

Estado Civil: _____________________________________________________________

Creencia religiosa: ________________________________________________________

Entidad de salud: ______________________ Estrado: _____________________

Dirección y barrio: _________________________________________________________

Teléfonos de contacto: _____________________________________________________

Correo electrónico: ________________________________________________________

Acudiente o contacto de emergencia: __________________________________________

Teléfonos: _______________________________________________________________

Personas con quien vive: ___________________________________________________

Fecha 1ª. Sesión: ________________________________________________________

2. MOTIVO DE CONSULTA

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3. PROBLEMÁTICA ACTUAL

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4. ANTECEDENTES PERSONALES

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5. ANTECEDENTES FAMILIARES

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6. GENOGRAMA

7. HIPÓTESIS

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8. INTERVENCIÓN PROPUESTA

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9. POSIBLE DIAGNOSTICO (DSM V ó CIE-10)

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Psicólogo(a): ____________________________

HISTORIA CLÍNICA No.____________________

Intervención No. _________________

Fecha: ________________________________

DESARROLLO DE INTERVENCIÓN

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Psicólogo(a): ____________________________