I.E Santa Isabel Dpto.

Psicología

FICHA DE DERIVACIÓN:

Datos de filiación:_________________________________________________________

Apellidos y Nombres:____________________________________________________________

Edad:_________________________________________

Grado y Sección:_______________________________________________________________

Fecha:___________________________________________________________________

I. Motivo de Derivación:

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

II. Problemas Emocionales y Comportamiento

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

_____________________________________________________________________________
III. EMOCIONALES CONDUCTUALES
- Tristeza ( ) - come las uñas ( )
- Desánimo ( ) - golpea ( )
- Llora ( ) - se saca los cabellos ( )
- Reniega ( ) - se distrae mucho ( )
- Ira ( ) - cansancio ( )
- Miedo ( ) - fatiga ( )