Modelo Historia Clínica Psicológica Espaciada

HISTORIA CLÍNICA PSICOLÓGICA. ANAMNESIS I.

Datos de Filiación: • Nom. y Apell._____________________________________________________________________: • Sexo : ____________ Edad :___________ Fecha de Nac.___________________: • Lugar de Nac._________________________________: Procedencia_______: • Dirección : ______________________________________ Télf:________________________ • Grado de Inst.________________________________: Religión_______________: • Estado Civil : ______________________________ Ocupación_________________________: • Padre : __________________________________________ Edad:____________________ • Madre : __________________________________________ Edad:____________________ • Referente : ______________________________________________________________________ • Informantes : ______________________________________________________________________ • Lugar de Eval.____________________________________________________________________: • Fechas de Eval.___________________________________________________________________: • Examinador : Psicólogo Jorge Luis Fernández Salguero.

II. Motivo de Consulta: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ III. Historia de la Enfermedad o del problema actual: A. Tiempo: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ B. Forma de Inicio: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ C. Síntomas Principales: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ D.Relato: ____________________________________________________________________________________

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ E. Antecedentes Clínicos: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ IV. Antecedentes Personales: A. Etapa Pre-natal: “Embarazo o gestación” ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ B. Etapa Natal: “Parto” ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ C. Etapa Post-Natal:  Primer Año: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________  Desarrollo Neuro-Psicomotor: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

D.Rasgos Neuropáticos: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ E. Etapa Escolar: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ F. Desarrollo y Función Sexual:  Aspectos Fisiológicos: (Sexo masculino. Sexo Femenino): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________  Aspecto psicosexual y Matrimonio: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ G.Actividad Laboral: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ H.Servicio Militar: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ I. Religión: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ J. Hábitos e influencias nocivas o tóxicas: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ K. Historia de la Recreación y de la vida: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ L. Enfermedades y accidentes: ____________________________________________________________________________________

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ M. Personalidad Premórbida: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ V. Antecedentes Familiares: A. Composición Familiar: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ B. Dinámica Familiar (Hábitos, costumbres): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ C. Condición Socioeconómica (vivienda, condiciones sanitarias, ubicación sociocultural, ocupación): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ D.Antecedentes Patológicos: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ VI. Resumen: _______________________________________________________________________________________

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EXÁMEN PSICOLÓGICO O MENTAL I.

Datos de Filiación: • Nom. y Apell._____________________________________________________________________: • Sexo : ____________ Edad :___________ Fecha de Nac.___________________: • Lugar de Nac.________________________________: Procedencia_______: • Dirección : ______________________________________ Télf:________________________ • Grado de Inst._______________________________: Religión_______________: • Estado Civil : ______________________________ Ocupación_________________________: • Padre : __________________________________________ Edad:____________________ • Madre : __________________________________________ Edad:____________________ • Referente : ______________________________________________________________________ • Informantes : ______________________________________________________________________ • Lugar de Eval.____________________________________________________________________: • Fechas de Eval.___________________________________________________________________: •

Examinador : Psicólogo Jorge Luis Fernández Salguero.

II. Actitud Porte y Comportamiento: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ III. Atención, Conciencia y Orientación: Atención y Concentración: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Conciencia o Estado de Alerta: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Orientación: (Tiempo, espacio, lugar, persona y personas). ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ IV. Lenguaje: (Ritmo, tono, contenido) _______________________________________________________________________________________

_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ V. Pensamiento: (Curso y contenido) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VI. Percepción: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VII.Memoria: (Corto y largo plazo) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VIII. Funcionamiento Intelectual: Conocimientos Generales. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Memoria. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Pensamiento: Razonamiento y Juicios ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ IX. Estado de Ánimo y Afectos: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ X. Comprensión y Grado de Incapacidad del Problema o Enfermedad: _______________________________________________________________________________________

_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ XI. Resumen: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

INFORME PSICOMÉTRICO. I.

Datos de Filiación: • Nom. y Apell._____________________________________________________________________: • Sexo : ____________ Edad :___________ Fecha de Nac.___________________: • Lugar de Nac._________________________________: Procedencia_______: • Dirección : ______________________________________ Télf:________________________ • Grado de Inst.________________________________: Religión_______________: • Estado Civil : ______________________________ Ocupación_________________________: • Padre : __________________________________________ Edad:____________________ • Madre : __________________________________________ Edad:____________________ • Referente : ______________________________________________________________________ • Informantes : ______________________________________________________________________ • Lugar de Eval.____________________________________________________________________: • Fechas de Eval.___________________________________________________________________: • Examinador : Psicólogo Jorge Luis Fernández Salguero.

II. Observaciones Generales: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ III. Instrumentos Utilizados: ψ ψ ψ ψ ψ ψ ψ IV. Interpretación de los instrumentos: _______________________________________________________________________________________

_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ V. Resumen: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _____________________________ Fernández Salguero Jorge Luis Psicólogo

INFORME PSICOLÓGICO I.

Datos De Filiación: • Nom. y Apell._____________________________________________________________________: • Sexo : ____________ Edad :___________ Fecha de Nac.___________________: • Lugar de Nac._________________________________: Procedencia_______: • Dirección : ______________________________________ Télf:________________________ • Grado de Inst.________________________________: Religión_______________: • Estado Civil : ______________________________ Ocupación_________________________: • Padre : __________________________________________ Edad:____________________ • Madre : __________________________________________ Edad:____________________ • Referente : ______________________________________________________________________ • Informantes : ______________________________________________________________________ • Lugar de Eval.____________________________________________________________________: • Fechas de Eval.___________________________________________________________________: • Examinador : Psicólogo Jorge Luis Fernández Salguero.

II. Motivo de Consulta: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ III. Técnicas e instrumentos Utilizados: ψ Observación. ψ Entrevista. ψ Historia Clínica. ψ Pruebas Psicométricas _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ IV. Antecedentes Personales y Familiares: _______________________________________________________________________________________

_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ V. Observaciones Conductuales. _______________________________________________________________________________________

_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VI. Análisis e Interpretación de los Resultados. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VII.Diagnóstico o Conclusión. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VIII. Pronóstico. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ IX. Recomendaciones: ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ

PLAN PSICOTERAPEÚTICO I.

Datos de Filiación: • Nom. y Apell.________________________________________________________________: • Sexo : ____________ Edad :___________ Fecha de Nac.______________: • Lugar de Nac._________________________________: Procedencia__: • Dirección : ______________________________________ Télf:___________________ • Grado de Inst.________________________________: Religión__________: • Estado Civil : ______________________________ Ocupación____________________: • Padre : __________________________________________ Edad:_______________ • Madre : __________________________________________ Edad:_______________ • Referente : _________________________________________________________________ • Informantes : _________________________________________________________________ • Lugar de Eval._______________________________________________________________: • Fechas de Eval.______________________________________________________________: • Examinador : Psicólogo Jorge Luis Fernández Salguero.

II. Diagnóstico Psicológico: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ III. Objetivos Generales: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ IV. Objetivos Específicos: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ V. Técnicas Terapéuticas: ψ ψ ψ ψ ψ ψ ψ ψ

VI.

Actividades

Psicoterapéuticas:

SESIÓ N

TÉCNICAS REALIZADAS “

P R I M E R A

”

Objetivos

Acciones Especificas

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

SESIÓ N

TÉCNICAS REALIZADAS “

S E G U N D A

”

Objetivos

Acciones Especificas

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

SESIÓ N

TÉCNICAS REALIZADAS “

T E R C E R A

”

Objetivos

Acciones Especificas

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

SESIÓ N

TÉCNICAS REALIZADAS “

C U A R T A

”

Objetivos

Acciones Especificas

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

SESIÓ N

TÉCNICAS REALIZADAS “

Q U I N T A

”

Objetivos

Acciones Especificas

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

SESIÓ N

TÉCNICAS REALIZADAS “

S E X T A

”

Objetivos

Acciones Especificas

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

SESIÓ N

TÉCNICAS REALIZADAS “

S E P T I M A

”

Objetivos

Acciones Especificas

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

SESIÓ N

TÉCNICAS REALIZADAS “

O C T A V A

”

Objetivos

Acciones Especificas

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

SESIÓ N

TÉCNICAS REALIZADAS “

N O V E N A

”

Objetivos

Acciones Especificas

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

SESIÓ N

TÉCNICAS REALIZADAS “ Objetivos

” Acciones Especificas

____________________________ ___________________________________________________

VII.

Tiempo de Ejecución: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

VIII.

Avances y Logros Terapéuticos: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Arequipa

de

del 2010