Ficha Parejas Psicología
Ficha Parejas Psicología
Ficha Parejas Psicología
1. Datos de Identificación:
1. Nombre:____________________________________________________________
Rut:________________________________________________________________
Fecha y Lugar de Nacimiento:___________________________________________
Edad:_________________ Sexo:____________________ Etnia:________________
Nivel de Escolaridad:__________________________________________________
Religion:____________________________________________________________
2. Nombre:____________________________________________________________
Rut:________________________________________________________________
Fecha y Lugar de Nacimiento:___________________________________________
Edad:_________________ Sexo:____________________ Etnia:________________
Nivel de Escolaridad:__________________________________________________
Religion:____________________________________________________________
Dirección Domiciliaria:_________________________________________________
Teléfono / Email:______________________________________________________
_________________________________________fecha: _____________________
3. Motivo de Consulta
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4. Anamnesis
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5. Genograma
6. Hipótesis diagnostica:
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7. Plan de Tratamiento
Sesiones cada: 1 semana 15 dias 1 vez al mes