I.E.P.
“San Juan Bautista de la Salle”
Paita
FICHA DE ORIENTACIÓN Y CONSEJERÍA
I. DATOS GENERALES:
Nombres y apellidos : ______________________________________________________
Sexo : ____________________ Edad :______________________
Fecha y lugar de nacim : ______________________________________________________
Número de hermanos : ______________________________________________________
Lugar entre hermanos : ______________________________________________________
Residencia actual : ______________________________________________________
Número de celular : ______________________________________________________
Grado de instrucción : ______________________________________________________
Ocupación : ____________________ Estado civil :__________________
Vino con : ______________________________________________________
Fecha : ______________________________________________________
Evaluador : ______________________________________________________
II. MOTIVO DE CONSULTA
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III. OBSERVACIÓN GENERAL DE LA CONDUCTA
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IV. OBJETIVO DE LA ORIENTACIÓN Y CONSEJO
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V. ACTIVIDAD REALIZADA
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Consultorio Psicológico