Entrevista Psicolgica para Adulto/a1. Datos de Identificacin: Nombre_________________________________________________________ Edad _______________________Cdula _____________________________ Estado Civil ______________ Escolaridad_______________Ocupacion______________________________Do micilio________________________________________________________Telefo no________________ Derivacin _______________________________ Fecha ____________________Terapeuta______________________________

2. Encuadre al entrevistado en donde se explica que primeramente se realizar un recorrido por su historia familiar y las diferentes etapas dentro del desarrollo de su vida.

3. Genograma

4. Observaciones A) Queja inicial __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ B) Porque ahora ____________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ C) Motivo de la consulta ______________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ D) Historia y circunstancia actual del motivo de consulta (dnde, cundo, cmo, con quin) __________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ________________________________________ E) Que deja de hacer o quisiera hacer y no hace como consecuencia del problema ____________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________ F) SOLUCIONES INTENTADAS 1. Por el paciente identificado _______________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ ___________________________________________ 2. Por los otros __________________________________________ _______________________________________________________ _______________________________________________________ ______________________________________________

3. Exitosas _____________________________________________ _______________________________________________________ _________________________________________________ Se mantuvieron____________________________________________________ ________________________________________________________________ No se mantuvieron _________________________________________________ ___________________________________________________________________ _____________________________________________________________ Porque fueron abandonadas? ______________________________________ ___________________________________________________________________ ___________________________________________________________________ __________________________________________________________ 5. TRATAMIENTOS ANTERIORES _______________________________ ____________________________________________________________ ________________________________________________________ A) Que sirvi _______________________________________________ __________________________________________________________ __________________________________________________________ _________________________________________________ B) Que no sirvi ____________________________________________ __________________________________________________________ __________________________________________________________ _________________________________________________ 6. TRATAMIENTOS ACTUALES ( de cualquier tipo que se consideren pertinentes) ________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ __________________________________________________ 7. ACTITUDES Y OPINIONES IMPORTANTES DE LAS PERSONAS SIGNIFICATIVAS ___________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ______________________________________________ 8. POSICIONES Y LENGUAJE DEL CONSULTANTE QUE PUEDEN SER UTILES ___________________________________________________ ____________________________________________________________ ____________________________________________________________

____________________________________________________________ ____________________________________________________ 9. MOTIVACION A) Qu objetivos busca al consultar? ___________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ B) Qu espera que haga el terapeuta? _________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________ 10.DIAGNOSTICO _____________________________________________ ____________________________________________________________ ____________________________________________________________ ______________________________________________________ 11.META MINIMA PACTADA CON EL CONSULTANTE Y REACCION DE ESTE _____________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________ 12.OBJETIVOS DEL TERAPEUTA Corto plazo ________________________________________________ ____________________________________________________________ ____________________________________________________________ ______________________________________________________ Mediano plazo ______________________________________________ ____________________________________________________________ ____________________________________________________________ ______________________________________________________ Largo plazo ________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ __________________________________________________

13.INTERVENCIONES DE ADMISOR Y PRIMERA REACCION DEL CONSULTATNTE A) Reformulaciones _________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ B) Prescripciones o sugerencias _______________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ C) Indicaciones de tipo de tratamiento y sus razones _______________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ______________________________________________ 14.PREDICCIONES ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________ 15.ESTRATEGIAS A SEGUIR ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________ 16.QUIENES SON CITADOS PARA LA PROXIMA SESION ____________________________________________________________ ________________________________________________________ 17.NUMERO DE SESIONES PREVISTAS __________________________ 18.NUMEROS DE SESIONES REALIZADAS ________________________

______________________________ Profesional - Firma