PROTOCOLO DE PERICIA PSICOLOGICA PARA REOS EN CARCEL POR DCLS.doc

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PROTOCOLO DE PERICIA PSICOLOGICA PARA REOS EN CARCEL-…..-2011-PSC

SOLICITADO POR:…………………………………………………………………………………….

OFICIO:…………………………………………………………………………………….

TIPO:……………………………………………………………………………………

I. DATOS DE FILIACIONAPELLIDOS:

…………………………………………………………………………………………………………………………….NOMBRES:

…………………………………………………………………………………………………………………………….SEXO:

……………………………………………………………………………………………………………………………LUGAR DE NACIMIENTO:

……………………………………………………………………………………………………………………………

FECHA DE NACIMIENTO:……………………………………………………………………………………………………………………………EDAD:

……………………………………………………………………………………………………………………………ESTADO CIVIL

……………………………………………………………………………………………………………………………

GRADO DE INSTRUCCIÓN:

……………………………………………………………………………………………………………………………OCUPACION:

……………………………………………………………………………………………………………………………RELIGION:

……………………………………………………………………………………………………………………………DOMINANCIA:


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……………………………………………………………………………………………………………………………PROCEDENCIA:

……………………………………………………………………………………………………………………………INFORMANTE:

…………………………………………………………………………………………………………………………..DOCUMENTO DE IDENTIDAD:………………………………………………………………………………………………………………………….LUGAR Y FECHA DE LA EVAL.:…………………………………………………………………………………………………………………………….

II. MOTIVO DE EVALUACIONA.- RELATOEx!"#$% &'('&': P%& )*+ ', $''#"$%/ S" ' %!","3#:

• 3!% ,*'$"3/• D'',: 4'56 *7& 8,6 *&%6 !%96 "'!% 8!#6 &$'6#%5'96 *,% $' ''!'#%, 8&'7%,6 &!,6 '96 4%&!, 8%!"'#%,6 ,'x% ;7"#6#6 %&96 &'"%#', $' ;


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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..B.- HISTORIA PERSONAL1.- PERINATAL:…………………………………………………………………………………………………………………………………………………..2.-NI@E:…………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

• C%#;";'#" ? &'"3# '#&' $&',: P&%==' 'x%,""3# ;"%'#"4!""&. M%$'%, &'#', #'7";%,. C&'#", A4'";,. A*,'#" $' 5%7& ',='8"#>*?' '# ,* $',&&%% 4'";% '!%"%# ? ,"%,%"9.• C%!%&!"'#%6 ,"7%,: M&% I#4#".• T'!%&',: !"'$%, "#4#"',6 !"'$% &',*#% 7&',%& ,'x*.• Ex'&"'#" N'7";: I!%&#' ," !'#"%# ' ';'#% &'"%#$% $'#*#": "#$"&


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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

• R'"3# %# %, $&',: ,%=&'&%'"3#6 ,%=&'%#&%6 $"#!" ;'&"6&%5"="";% ? ,"7$%& 8"#$"&"% %# ' '#%% 4!""&9.•

C%!%&!"'#%: &'='$"";6 4*7, 8"#$"&


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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..R';",, ,'x*',:……………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………..P'


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…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

T"% $' &':…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….H%&&"%:……………………………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..L*7&:………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………….F&'*'#":………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

T"% $' C%"%:………………………………………………………………………………………………………………………

…………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..P%,""3# !%&":…………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………..D*&"3#:……………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………….


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O&7,!%:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..M.A.C………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………F#,


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……………………………………………………………………………………………………………………………………………………………………………V"$ S'x* A*:…………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

J.- ANTECEDENTES PATOLOGICOS:9 E#4'&!'$$',:……………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………=9 A"$'#',:………………………………………………………………………………………………………………………

…………………………….……………………………………………………………………………………………………………………………………………………………………………9 O'&"%#',:………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………$9 T&!"'#% P,")*"&"%KP,"%37"%:…………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………

.- ANTECEDENTES UDICIALES:………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

C.- HISTORIA FAMILIARPADRE:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..D%, 7'#'&',. R% $' $&'. D',&""3# $' &'&. S'#"!"'#%,.O& &' 8," % 5*="'&9. R'"%#', 4&'#' %, H'5%,.

P$&,&%: 8," % 5*="'&9. D%, 7'#'&',. T"% $' &'"3#. S'#"!"'#%,.

MADRE:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………..D%, 7'#'&',. R% $' !$&'. D',&""3# $' &'&.S'#"!"'#%,. O& &'. R'"%#', 4&'#' %, H'5%,.


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HERMANOS:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..N!'&% $' 5'&!#%,6 &'"%#',6 &%==' %&, ;


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AREA ORGANICIDAD:

AREA INTELIGENCIA:

AREA PERSONALIDAD:

AREA DINMICA FAMILIAR:

V.- CONCLUSIONES

DESPUES DE EVALUAR A ……………………………………………………. SE ES DE LA OPINIONUE PRESENTA:

-

-OBSERVACIONES

DATOS ADICIONALES DEL PSICÓLOGO FORENSE UE SUSCRIBE:

D.N.I. 102Q

DIRECCIÓN: MNA. G6 LOTE 10. URB. PALMA BELLA

CHEPEN6 …… DE ………………DEL 2010

………….…………………………………………………………

PAOLA NILDA GALVAN MATTOS

C.PS.P. 1211

PROTOCOLO DE PERICIA PSICOLOGICA PARA REOS EN CARCEL POR DCLS.doc

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