1.

1 PSYCHOLOGICAL INTERVIEW
GENERAL DATA:

1. Name: _______________________________________________________
2. Place and Date of Birth: __________________________________
3. Age in years and months: _______________________ sex: ___________
4. Address and telephone: ___________________________________________
5. School grade: ____________ School: ___________________________
6. Current status (reason for consultation): _____________________________
________________________________________________________________
________________________________________________________________

II. FAMILY HISTORY:

1. Father: ________________________________________ Age: ___________ Occupation:
_____________________________________________________ Addictions:
_____________________________________________________ Relationships with the
child: stable, unstable, conflictive, much, little, no communication.
2. Mother: ________________________________________ Age: __________ Occupation:
_____________________________________________________ Addictions:
_____________________________________________________ Relationships with the
child: stable, unstable, conflictive, much, little, no communication
3. Relationships: good, average, bad, separated, divorced, total abandonment of a member.
Specify reasons: ____________________________________________
________________________________________________________________
4 . Siblings: sex and age: ________________________________________
________________________________________________________________
Relationships with the child (each sibling) stable, unstable, conflictive, much, little, no
communication.
5 . Family background:
Medical: _______________________________________________________ Psychiatric:
___________________________________________________
Toxic: ________________________________________________________
6. Reactions of parents to the child's problem
________________________________________________________________
________________________________________________________________

III. PERSONAL HISTORY.

1. History: Pregnancy: __________________
2. Desired child: _____________________
3. Prenatal difficulties (medical, abortion attempts, psychological):
________________________________________________________________
________________________________________________________________

4.- Perinatal period:

 Childbirth: _______________________________________ (normal), (anoxia),
(umbilical cord), (placenta), (malformation), (jaundice), (maternal pregnancy).
Birth weight: _________________
Size at birth: __________________
Breastfeeding until _____________ months, with a bottle until ____________ months.
Types of semisolids introduced: ______________________________ Types of solids
introduced: __________________________________
Feeding problems at birth and up to the first year:
________________________________________________________________
Sleeping difficulties: _____________________________________________ Child's
reactions: calm, restless.
Crawling age: __________ Standing age: _______________
Age at walking: ______________ Beginning of language: _____________ Medical
illnesses: ________________________________________ Hospitalizations and
surgeries: ____________________________________ Visual-perceptual motor
problems: _____________________________________
________________________________________________________________
IV.-School Background
School level: _____________________ Academic index: ___________
School: _______________________________________________________
How was the process of adaptation to school?:
________________________________________________________________ School
problems (academic), (behavioral): _____________
________________________________________________________________
What do you like most about school?: ______________________________
________________________________________________________________
What do you not like about school?: ________________________________
________________________________________________________________ How is it
with homework?: ______________________________________
How do you handle school supplies?: ____________________________
What problems do you have at the level of reading, writing,
calculation?:________________________________________________________________
________________________________________________________________ How do you
relate to the teacher?: ____________________________
________________________________________________________________ How do you
relate to your classmates?: _______________________
________________________________________________________________

V.-Socialization and emotional aspects:

Do you make friends easily? (communicative, uncommunicative, participates in a group,
tendency to isolate, passive, aggressive, dependent, independent).
________________________________________________________________
________________________________________________________________
What age are the children you interact with?
________________________________________________________________
What type of games do you play? ____________________________________
What does he do with other children of the same sex?: __________________
________________________________________________________________ How does
he relate to children of the other sex?: _________________
________________________________________________________________
Why do you fight with other children?: _______________________
________________________________________________________________
What makes you happy?: ____________________________________________
What makes you sad?: ___________________________________________
What makes you angry?: ________________________________________________
What aspects of life do you ask about most frequently?:
________________________________________________________________
________________________________________________________________
How well do you bathe, dress, eat, sleep, currently?
_______________________________________________________________
_______________________________________________________________
Interests and hobbies: What do you like to do in your free time?:
________________________________________________________________
What do you do when you are alone?
_________________________________________________________________ He does
not like to do?
_________________________________________________________________
What kind of sports do you like?
_________________________________________________________________
What are your favorite games? Have you ever played doctor, mom and dad?
_________________________________________________________________
What television programs do you watch?
___________________________________________________________________

VI.-Psychosexual Development:
Weaning: _____________
What type of food do you prefer?:
_________________________________________________________________ Have
you ever stopped feeding?: ____________________________ Anal control: _________
daytime bladder: _____________night bladder: _____________ technique:
__________________________
_________________________________________________________________

What reactions do you have when defecating? (disgust, shame, fear, pleasure,
displeasure)
_________________________________________________________________Finger
sucking: _________________
Masturbation: _______________
Who do you sleep with?: _____________________________________________ Have
you ever observed sexual acts?: ________________________
_________________________________________________________________What
knowledge do you have about sexuality?
_________________________________________________________________
Acquired sexual information and sources: ___________________________
_________________________________________________________________Pread
olescence and adolescence: Menarche: ______________
 Experience: __________________________
Pollution: ________________ experience: __________________________
Was he informed?: _______________________________________________
Emotional reactions typical of adolescence: (extroverted, shy, anxious, willful, moody,
labile).
_________________________________________________________________
_________________________________________________________________
Courtship: _________
Family acceptance or family restriction regarding courtship:
_________________________________________________________________ 6.
Neurotic Symptoms:
Nightmares: __________
Night terrors: _____________________
Sleepwalking: _____________
Tantrums: _____________________
Regressions: ________________
Enuresis: _______________________
Encopresis: _________________
Onychophagia: ____________________
Trichotillomania:______________ language problems: ______________
Tics: ________________________
Seizures: __________________
Heist: _______________________
Lie: _______________________

VII.-Punishments:
Who is responsible for discipline?:
_________________________________________________________________
What behaviors of the child bother you?
________________________________________________________________
What type of punishments do you frequently use?
________________________________________________________________
VIII -Observations
Finals:
______________________________________________________________________
____________________________________________________________