Entrevista Psicolgica para Adulto/a

1. 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
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B) Porque ahora ____________________________________________
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C) Motivo de la consulta ______________________________________
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D) Historia y circunstancia actual del motivo de consulta (dnde, cundo,
cmo, con quin) __________________________________
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E) Que deja de hacer o quisiera hacer y no hace como consecuencia del
problema ____________________________________________
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F) SOLUCIONES INTENTADAS
1. Por el paciente identificado _______________________________
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2. Por los otros __________________________________________
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3. Exitosas _____________________________________________
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Se mantuvieron____________________________________________________
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No se mantuvieron _________________________________________________
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Porque fueron abandonadas? ______________________________________
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5. TRATAMIENTOS ANTERIORES _______________________________
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A) Que sirvi _______________________________________________
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B) Que no sirvi ____________________________________________
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6. TRATAMIENTOS ACTUALES ( de cualquier tipo que se consideren
pertinentes) ________________________________________________
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7. ACTITUDES Y OPINIONES IMPORTANTES DE LAS PERSONAS
SIGNIFICATIVAS ___________________________________________
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8. POSICIONES Y LENGUAJE DEL CONSULTANTE QUE PUEDEN SER
UTILES ___________________________________________________
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9. MOTIVACION
A) Qu objetivos busca al consultar? ___________________________
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B) Qu espera que haga el terapeuta? _________________________
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10.DIAGNOSTICO _____________________________________________
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11.META MINIMA PACTADA CON EL CONSULTANTE Y REACCION DE
ESTE _____________________________________________________
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12.OBJETIVOS DEL TERAPEUTA
Corto plazo ________________________________________________
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Mediano plazo ______________________________________________
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Largo plazo ________________________________________________
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13.INTERVENCIONES DE ADMISOR Y PRIMERA REACCION DEL

CONSULTATNTE
A) Reformulaciones _________________________________________
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B) Prescripciones o sugerencias _______________________________
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C) Indicaciones de tipo de tratamiento y sus razones _______________
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14.PREDICCIONES
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15.ESTRATEGIAS A SEGUIR
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16.QUIENES SON CITADOS PARA LA PROXIMA SESION
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17.NUMERO DE SESIONES PREVISTAS __________________________
18.NUMEROS DE SESIONES REALIZADAS ________________________

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Profesional - Firma