PRIMERA ENTREVISTA
FECHA: _________________________
1. DATOS GENERALES
NOMBRE: _________________________________________________________________
EDAD: ________________ SEXO:_____________
OCUPACIN: __________________
ESCOLARIDAD:________ INSTITUCION EDUCATIVA:____________________________
DOMICILIO: _______________________________________________________________
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TELEFONO FIJO: _______________ TELEFONO CELULAR:_______________________
REMITIDO POR: ____________________________________________________________
MOTIVO: __________________________________________________________________
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2. DATOS ACOMPAANTE
NOMBRE: _________________________________________________________________
EDAD: ________________ SEXO: ____________
OCUPACIN: __________________
DOMICILIO: _______________________________________________________________
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TELEFONO FIJO: ________________ TELEFONO CELULAR: ______________________
3. ANAMNESIS
3.1 PSICOGRAMA
4. MOTIVO DE CONSULTA
Presente virtual. (Frecuencia, duracin, intensidad)
Qu fue lo ltimo que ocurri para que decidiera venir al psiclogo?
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5. CUADRO CLINICO
Desde cuando empez el problema? (presente virtual) __________________________
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Como fue la ultima ocasin en que ocurri el problema?_________________________
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Qu ocurra en su vida antes de que surgiera la situacin? (factores
desencadenantes) __________________________________________________________
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5.1 FACTORES DESENCADENANTES:
Qu otros aspectos se vinculan con el problema? (ncleo)
FACTOR
ASOCIADO
FAMILIA
PAREJA
AMISTADES
ESCUELA
TRABAJO
SALUD
FISICA
DESCRIPCION
5.2 SOPORTE FAMILIAR, SOCIAL, LABORAL, PERSONAL (Andamiaje)
Autovaloracin: ____________________________________________________________
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Sueos y fantasas ms frecuentes: ___________________________________________
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Satisfaccin conyugal o de pareja: ____________________________________________
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Satisfaccin laboral o de estudios: ____________________________________________
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Situaciones, actividades y personas con las que se siente ms tranquilo: ___________
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Actividades gratificantes que realiza: __________________________________________
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6.Describa las actividades que realiza cotidianamente de lunes a vienes y
fines de semana
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MARTES __________________________________________________________________
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MIERCOLES _______________________________________________________________
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JUEVES___________________________________________________________________
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VIERNES _________________________________________________________________
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SABADO__________________________________________________________________
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DOMINGO_________________________________________________________________
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7. CONTEXTO DE VIDA
ETAPA DE LA INFANCIA 0 5 AOS ( ASPECTOS: 1.SALUD FISICA 2.ESCOLAR
3.AMISTADES 4.FAMILIA 5.PERSONALIDAD 6.PAREJA 7.TRABAJO)
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7. CONTEXTO DE VIDA
ETAPA DE LA NIEZ 6 12 AOS ( ASPECTOS: 1.SALUD FISICA 2.ESCOLAR
3.AMISTADES 4.FAMILIA 5.PERSONALIDAD 6.PAREJA 7.TRABAJO)
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7. CONTEXTO DE VIDA
ETAPA DE LA ADOLESCENCIA 13 18 AOS (ASPECTOS: 1.SALUD FISICA
2.ESCOLAR 3.AMISTADES 4.FAMILIA 5.PERSONALIDAD 6.PAREJA 7.TRABAJO)
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7. CONTEXTO DE VIDA
ETAPA DE LA JUVENTUD 18 - 35 AOS ( ASPECTOS: 1.SALUD FISICA
2.ESCOLAR 3.AMISTADES 4.FAMILIA 5.PERSONALIDAD 6.PAREJA 7.TRABAJO)
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7. CONTEXTO DE VIDA
ETAPA DE LA ADULTEZ 35 AOS EN ADELANTE ( ASPECTOS: 1.SALUD
FISICA
2.ESCOLAR
3.AMISTADES
4.FAMILIA
5.PERSONALIDAD
6.PAREJA
7.TRABAJO)
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8. CONCLUSIONES
8.1 CONCLUSIONES EVIDENTES: (Lo que esta claro)
DESCRIPCION - Dimensin principal - Duracin, frecuencia, intensidad.
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Por qu se genero? - Causas, antecedentes histricos.
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Por qu se mantiene? - Factores involucrados.
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Relacin entre los diferentes problemas.
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Recomendaciones Tcnicas, sugerencias, etc.
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8.2 CONCLUSIONES HIPOTTICAS: (Lo que hay que comprobar)
DESCRIPCION - Dimensin principal - Duracin, frecuencia, intensidad.
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Por qu se genero? - Causas, antecedentes histricos.
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Por qu se mantiene? - Factores involucrados.
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Relacin entre los diferentes problemas.
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Recomendaciones Tcnicas, sugerencias, etc.
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9.1
PRONOSTICO A (SIN PSICOTERAPIA)
FACTORES RELEVANTES
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TENDENCIAS
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ESCENARIO 1 (Lo ms probable)
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PLAZO (Corto Mediano - Largo)
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ESCENARIO 2 (En el mejor de los casos)
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PLAZO (Corto Mediano - Largo)
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9. 2
PRONOSTICO B (CON PSICOTERAPIA)
FACTORES RELEVANTES
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RECURSOS POSITIVOS
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ESCENARIO 3 (Lo ideal a lograr con psicoterapia)
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PLAZO (Corto Mediano - Largo)
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ESCENARIO 4 (Lo mnimo que se espera lograr con psicoterapia)
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PLAZO (Corto Mediano - Largo)
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10.1. ANALISIS SEMIOTICO
Marca con una X.
o ASPECTO CORPORAL:
Complexin, edad que corresponde al aspecto fsico, gesticulacin, talla
baja o alta,
delgadez, exceso de peso, mano y uas limpias, etc.
o ARREGLO PERSONAL:
Arreglo, desalio, olor, vestido, maquillaje, peinado, accesorios, calzado, etc.
o COMPORTAMIENTO:
Lenguaje, se precipita en sus respuestas ,silencios , tono de voz, palabras rebuscadas,
calo, gestos, relajado, tenso, llanto, bostezo,
conversador, contacto visual,
expresin
facial concuerda con mensaje verbal, sonrisa, distancia que guarda al sentarse, postura
cmoda,
posturas abatidas o de decaimiento, cabeza alta, espalda
recta, brazos
apoyados en el asiento, movimiento excesivo de manos, forma de sentarse
o DESCRIPCION GENERAL:
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ASPECTO CORPORAL
COMPLEXIN
EDAD
APARENTE
Talla baja
Talla alta
Exceso de
peso
delgadez
menor
mayor
o NIVEL DE EMPATIA:
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MB____
B____
R____
M____
10.2. ANALISIS SEMIOTICO.
COMPORTAMIENTO
Confiado
desconfiado
Extrovertido
introvertido
tranquilo
inquieto
cooperador
renuente
interesado
aptico
amable
descorts
relajado
tenso
ESTILO DE VESTIR
BIEN
DEPORTIVO
FORMAL
CASUAL
ALIO
REGULAR
MAL
ARREGLO PERSONAL
CUIDADO
DESCUIDADO
CABELLO
UAS
MAQUILLAJE
HIGIENE
OLOR
AGRADABLE DESAGRADALE
EMOCIONES
Miedo
Alegra
Tristeza
Enojo
Amor
POSTURA
Cmoda
Piernas cruzadas
Piernas
abatido
extendidas
Movimiento
decado
excesivo de
manos
Espalda
rigidez
encorvada
Distancia que
Espalda recta
guarda al
sentarse
Brazos
apoyados
Brazos
cruzados
NIVEL DE EMPATIA
EXCELENTE
MUY BUENO
BUENO
REGULAR
MALO
LENGUAJE
Precipita en sus
Contacto visual
respuestas
Expresin facial
Silencios
concuerda con
mensaje verbal
Palabras
Aumento de voz
rebuscadas
Calo
Voz baja
Gesticulacin
Conversador
Bostezo
INTERPRETACION GENERAL:
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ENTREVIST:
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