Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
COUNSELING REFERRAL FORM
Name of Student:
Grade & Level:
Gender:
Date of Referral:
Reason/s for Referral:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Initial Actions Taken:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
____________
Did the student agree to be referred to GCO: ___ YES ___ NO
Parent/Guardian’s Name:
Parent/ Guardian’s Contact Number:
Referred by:
Designation:
Contact Number:
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
COUNSELING REFERRAL ACKNOWLEDGEMENT FORM
To: (Referring Person/Unit)
Designation/Department:
This is to confirm that _______________________________ whom you
referred to us on _______________________________ had started his/her session
on _______________________ and is being attended by
_______________________.
Kindly refer to the checklist below on the status of the case at hand.
Closed at Intake Interview
For Counseling
Counseling Sessions are on-going
Parent/ Guardian Conference Conducted
Sessions Completed/ Case Terminated
Student did not show up
Under Monitoring
Number of follow-ups made by the counselor: ________
Referred to _____________________________________
Thank you,
Always for the welfare of students,
_______________________
Attending Guidance Counselor
Date:
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
ANNEX B.
INTAKE INTERVIEW FORM
Name: ________________________ : ___________________________
Birth Date: ______________ Sex: _____ Preferred Language: __________
We are concerned about how things are going for you. Our session today will help us
discuss what’s going O.K and what’s not going so well. Everything is confidential except for
those that need to be discussed with others in order to HELP you.
1. How would you describe your current situation? What problems are you
experiencing? What are your main concerns?
__________________________________________________________
__________________________________________________________
__________________________________________________________
2. How serious are these matters for you this time?
__ Vey serious __ Serious __ Not too serious __ Not serious at all
3. How long have you had these problems?
__ 0 -3 months __ 4 months to a year __ More than a year
4. What caused these problems?
__________________________________________________________
__________________________________________________________
__________________________________________________________
5. Do others (parents, guardians, and friends) think there were other causes? If so, what
do they say?
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
6. What other things are currently making it hard to deal with the problems?
__________________________________________________________
__________________________________________________________
__________________________________________________________
7. What have you already tried in order to deal with the problems?
__________________________________________________________
__________________________________________________________
__________________________________________________________
8. Why do you think these things didn’t work?’
__________________________________________________________
__________________________________________________________
__________________________________________________________
9. What have others advised you to do?
__________________________________________________________
__________________________________________________________
__________________________________________________________
10. What do you think would help to solve the problems?
__________________________________________________________
__________________________________________________________
__________________________________________________________
11. How much time and effort do you want to put into solving the problems?
__ None at all __ Only a little __ Just enough __Very much
If you answered 1st, 2nd, or 3rd option, why don’t you want to put more time and effort
into solving the problems?
__________________________________________________________
__________________________________________________________
__________________________________________________________
12. What type of help do you want?
__________________________________________________________
__________________________________________________________
__________________________________________________________
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
13. What changes are you hoping for?
__________________________________________________________
__________________________________________________________
__________________________________________________________
14. How hopeful are you about solving the problems?
__ Very hopeful __ Hopeful __ Somewhat hopeful __ Hopeless
If you are hopeless, why?
__________________________________________________________
__________________________________________________________
__________________________________________________________
15. What else should we know so that we can help? Are there any other matters you want
to discuss?
__________________________________________________________
__________________________________________________________
__________________________________________________________
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
For interviewer/counselor only: Do not write anything below the line.
==========================================================
Name of Interviewer/Counselor: ____________________________ Date: ________
Note the identified problem:
_______________________________________________________________
Is the counselee seeking help? Yes No
If not, what are the circumstances that brought the counselee to the interview?
_______________________________________________________________
_______________________________________________________________
Counselor’s Notes:
__________________________________________________________
__________________________________________________________
__________________________________________________________
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
ANNEX E.
COUNSELEE’S DATA
A. Personal Information
Name: _____________________________________________________
Grade Level & Section: ____________________ School: ________________
Birthday: ______________ (m/d/y) Age: _____ Birth Order: _____________
Address: ____________________________________________________
Contact Number: _____________________ Email Address: ______________
Gender: ( ) Female Nationality: ( ) Filipino
( ) Male ( ) Foreigner, pls. state country _______
Religion: ________________
Who are you staying with?
( ) Parents ( ) Relatives ( ) Own Family ( ) Alone/Dorm
B. Family Background
FATHER MOTHER
Name
Age
Educational Attainment
Occupation
Contact Number
Monthly Family Income: (Combined)
( ) below Php 10, 000.00
( ) Php 10,000.00 – 20,000.00
( ) Php 20, 000.00 – 30, 000.00
( ) above Php 30, 000.00
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
Parents’ Relationship Status
( ) Married and Living Together
( ) Married but Separated
( ) Both with other partners ( ) Not Married
( ) Father/Mother with another partner ( ) Deceased, pls. specify
_________________
( ) Both without parents
Siblings
(Use the back portion if necessary)
Name Age Educational Occupation
Attainment
In case of emergency:
Person to contact: ________________________________________________
Occupation: _____________________ Contact Number: __________________
Address: ______________________________________________________
C. Educational Background
Elementary: __________________ Year: _________ Honors incurred: ________
Secondary: ___________________ Year: _________ Honors incurred: ________
D. Health
Height: ________________ Weight: ________________ Blood Type: _____
Are you suffering from any ailments of handicap? ________________________
Are you under any medication? ____________________________________
Did you have any suicidal attempts or thoughts? If yes, when? ________________
Were you a victim of any form of abuse? If yes, when? _____________________
Did you get involved with illegal drugs? If yes, when? ______________________
Do you have a mentally challenged family member/relative? _________________
If yes, how are you related to him/her? _______________________________
Have you visited a psychiatrist or psychologist before? (If yes, state the reason.)
__________________________________________________________
__________________________________________________________
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
__________________________________________________________
__________________________________________________________
____________________________________ _______________
Counselee’s signature over printed name Date
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
GUIDANCE OFFICE
HOME VISITATION FORM
Date: _________________________________ Time: _______________
Name of Student: ___________________ Age: ____ Gender: ____________
Address: ____________________________________________________
Name of Parent/Guardian: _______________________________________
Parent’s/Guardian’s Feedback on Home Visitation:
__________________________________________________________
__________________________________________________________
__________________________________________________________
You may use another sheet
Other Issues discussed during the visit:
__________________________________________________________
__________________________________________________________
__________________________________________________________
You may use another sheet
Who were present during the home visitation?
__________________________________________________________
__________________________________________________________
__________________________________________________________
You may use another sheet
Remarks:
__________________________________________________________
__________________________________________________________
__________________________________________________________
You may use another sheet
________________________________________ ________________________________________
Signature over printed name of Parent/Guardian Signature over printed name adviser/teacher
___________________________________________________
Signature over printed name of Guidance Counselor/Designate
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN
ASK SUICIDE-SCREENING QUESTIONS (ASQ)
o Hinihiling mo ba ang iyong kamatayan sa mga nakalipas na linggo?
(Did you wish you were dead in the past few weeks?)
_________________________________________________
_________________________________________________
o Pakiramdam mo ba na mas bubuti ang iyong kalagayan at pamilya
kung nawala ka na sa mga nakalipas na linggo? (Have you felt that you
or your family would be better off if you were dead in the past few
weeks?)
________________________________________________
________________________________________________
o Nakakaisip ka bang magpakamatay sa mga nakalipas na linggo? (Have
you been having thoughts about killing yourself in the past week?)
_________________________________________________
_________________________________________________
o Nasubukan mo na bang magpakamatay dati? (Have you ever tried to
kill yourself?)
_________________________________________________
_________________________________________________
o Nakakaisip ka bang magpakamatay ngayon? (Are you having thoughts
of killing yourself right now?)
_________________________________________________
_________________________________________________
Address: Magsaysay, Dinalupihan, Bataan
Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@[Link]
