cvvcvchistoria clinica psicologia (1)
TRANSCRIPT
INSTITUCIÓN EDUCATIVA SANTA FE INFORME PSICOLOGICO
COGNITIVO Área de Psicología
Fecha informe: _____,_______,_______
Psicólogo (a) que atiende: _____________________________________
I. DATOS GENERALES
Nombre de niño (a) paciente: __________________________________________
Edad y meses ______________
Escolaridad: __________________
Remitido por: ________________________________________
Nombre de padres _______________________________________ edad ( )
_______________________________________ edad ( )
Dirección: _____________________________________________
Teléfono o celular de contacto: ______________________, _____________________
GENOGRAMA FAMILIAR:
II. MOTIVO DE CONSULTA ( análisis de la conducta o problemática) __________________________________________________________________________________________________________________________________________________
Elaborado por: Leidis Yohana Padilla [email protected]
Skype: oteropadilla
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________queja del paciente o persona que acompaña: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________expectativa del tratamiento: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
III. DIAGNOSTICO MULTIAXIAL:
EJE I:EJE II:EJE III:EJE IV:EJE V:
IV. ANALISIS DESCRIPTIVO
- Estudio sintomático y evolución de los síntomas
- Tiempo cero
V. TECNICAS DE EVALUACIÓN:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VI. CONDICIONES DE VIDA Y ANALISIS AMBIENTAL:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Elaborado por: Leidis Yohana Padilla [email protected]
Skype: oteropadilla
- Factores de riesgo: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Áreas:
Familiar: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Social: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Afectiva:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Académica: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Antecedentes familiares de enfermedades mentales o fisicas:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Dinámica familiar: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Factores predisponentes (biológicos, ambiental o psicológico) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Elaborado por: Leidis Yohana Padilla [email protected]
Skype: oteropadilla
Factores precipitantes: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VII. ANALISIS HISTORICO:
- Historia del problema
- Historia personal relevante
- Estudio genético biológico
VIII. ANALISIS ESTRUCTURAL
- Estrategias compensatorias:
- Esquemas mal adaptativos tempranos
Esquema nuclear Reglas Actitudes Supuestos condicionales
Elaborado por: Leidis Yohana Padilla [email protected]
Skype: oteropadilla
IX. ANALISIS FUNCIONAL
SITUACIÓN PENSAMIENTO EMOCIONES RESPUESTAS CONDUCTUALES
REACCIONES FISIOLOGICA
X. TECNICAS COGNITIVAS
XI. ESTRATEGIAS PARA INTERVENIR:
FASE 1: “Construyendo la confianza y estableciendo parámetros del tratamiento”
FASE 2: “Cambiar creencias”
FASE 3 “Previniendo caídas y preparando para la terminación”
Elaborado por: Leidis Yohana Padilla [email protected]
Skype: oteropadilla