COLEGIO SAN FRANCISCO DE ASS

Programa de Integracin Escolar PIE-SEP

PAUTA DE DERIVACIN DE CASOS

I - ANTECEDENTES PERSONALES

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Curso: __________ Nombre Profesor Jefe: ______________________________
Fecha de derivacin: _________________________________________________
II- MOTIVO DE DERIVACIN

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III- ANTECEDENTES PEDAGGICOS

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IV- ANTECEDENTES CONDUCTUALES

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V- INTERVENCIONES QUE SE HAN REALIZADO

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VI.- PROFESIONAL DERIVADO
EDUCADOR DIFERENCIAL ___________

FONOAUDIOLOGO ___________

PSICOLOGO _________

ASISTENTE SOCIAL ___________

NOMBRE DOCENTE

FIRMA