INFORME PSICOLÓGICO
1. DATOS DE IDENTIFICACIÓN
Nombres: _____________________________________________ Edad: ______________
Lugar y fecha de nacimiento: __________________________________________________
Género: _______________ Estado civil: ________________ Religión:_________________
Instrucción: __________________________ Ocupación:___________________________
Dirección: ________________________________________ Teléfono: _______________
Remitente: ________________________________________________________________
Lugar y fecha de Evaluación: __________________________________________________
2. MOTIVO DE CONSULTA
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3. HISTORIA PERSONAL Y FAMILIAR
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5. OBSERVACIONES GENERALES DE CONDUCTA:
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6. PRUEBAS PSICOLÓGICAS Y RESULTADOS
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7. FORMULACION DEL CASO (Análisis de hallazgos e interpretación de los resultados).
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8. DIAGNOSTICO (CIE 10 y DSM-5)
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9. PRONOSTICO
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10. RECOMENDACIONES
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Firma: _____________________
Fecha de entrega: ________________