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FICHA DE ATENCIÓN - PSICOLOGÍA

Fecha: ………………………………….
N° de atención:…………………….

I. DATOS DEL ALUMNO

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Edad: ……………………………...................Grado y Sección: ………..………………………………………………………………………………………………..
Dirección: ……………..………………………………………………………………………………………………………………………………………………………………
Nombre del papá, mamá o apoderado: ………………………………………………………………………………………………………………………………..

II. MOTIVO DE ATENCIÓN O DERIVACIÓN

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DESCRIPCIÓN DEL PROBLEMA


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III. COMPROMISO

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IV. APOYO A RECIBIR
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Firma y Sello del Psicólogo

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