Escolar Documentos
Profissional Documentos
Cultura Documentos
I. GENERAL DATA:
1. Nombre: _______________________________________________________
2. Place and Date of Birth: __________________________________
3. Age: _______________________ sex: ____________________________
4. Dirección y teléfono:
________________________________________________________________
________________________________________________________________
5. Población______________________________________________________
6. Estado Civil____________________________________________________
7. Ocupación_____________________________________________________
8. Reason for inquiry: ____________________________________________
9. Is it your first offense? Sí,
no_____________________________________
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Adicciones______________________________________________________
Dietas:__________________________________________________________
Accidentes, secuelas:____________________________________________
2. Level of education:
Escuela: _______________________________________________________
Bachiller________________________________________________________
Universidad_____________________________________________________
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________________________________________________________________
________________________________________________________________
Are you easily intimate with people of the other sex?
________________________________________________________________
Is it considered violent?
________________________________________________________________
What makes you happy?
____________________________________________
5. Psychosexual development:
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6. Neurotic Symptoms:
Nightmares: __________
Sleepwalking: _____________
Regressions: ________________
Enuresis: _______________________
Encopresis: _________________
Onicofagia: _____________________
Trichotillomania: ______________
language problems: ______________
Tics: ________________________
Seizures: __________________
Theft: _______________________
Mentira: _______________________
7. Punishments:
¿Soporta el castigo?:_______________________________________________
___________________________________________________________________
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8. criminal history:
__________________________________________________________________
______________________________________________________________________
______________________________________________________________________
____
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9. Concluding remarks:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________