Republic of the Philippines
Department of Education
REGION XI – DAVAO REGION
SDO - DIVISION
NAME OF SCHOOL
ADDRESS
STATEMENT OF CONFIDENTIALITY
Counseling services cater to the mental health and well-being of all learners. The
Guidance and Counseling Office recognizes that people are faced with various life
stressors that can interfere with their daily behavior and functions. Counseling
services are completely confidential.
There are few exceptions or limitations to confidentiality in counseling situations. The
following are the conditions to be considered in breaking the confidentiality in
counseling:
a. If you are becoming an imminent danger to yourself and/or to others such as
thoughts of suicide, or threats to harm other people.
b. If there is a reasonable suspicion of emotional and/or physical neglect and/or
abuse including sexual abuse of a minor.
c. In rare cases, courts will be asking guidance counselors to testify about you.
Confidentiality Guidelines
Many people are concerned about the confidentiality of meeting with a
counselor. The following guidelines provide information about the nature of our
services.
The following are kept confidential:
a. That you are seeing a counselor
b. All contact information, including your counseling schedules
c. The guidance counselor is the only person who has an access to the
information discussed, unless you give written permission for specific
information to be shared.
Rights and Responsibilities of Client
You have the right to:
• be treated with respect and consideration;
• know that information you share during the counseling process is confidential;
1
Republic of the Philippines
Department of Education
REGION XI – DAVAO REGION
SDO - DIVISION
NAME OF SCHOOL
ADDRESS
• discuss with your counselor any concerns or dissatisfaction you may have
about your counseling experience;
• refuse to complete any consent forms requested during counseling process;
• ask for referral to another counselor. You are responsible for:
• treating Guidance and Counseling Office personnel with respect and
consideration;
• maintaining the confidentiality of others in group counseling sessions (if
applicable)
• helping to make your counseling experience meaningful;
• letting us know immediately about any concern (s) you may have with our
service.
By signing this, I have read, understood and agreed on the provisions of this
Statement of Confidentiality of the Guidance and Counseling Office.
_________________________________ __________________
Parent’s Signature over printed name Date and Time
1
Republic of the Philippines
Department of Education
REGION XI – DAVAO REGION
SDO - DIVISION
NAME OF SCHOOL
ADDRESS
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 to discuss what's going O.K. and what's not going so well. Everything
is confidential except for those things 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 at this time?
___ Very Serious ___ Serious ___Not too serious ___Not serious at all
3. How long have these been problems?
___ 0-3 months ___4 months to a year ____more than a year
4. What caused these problems?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
5. Do others (parents, guardian, and friends) think there were other causes? If
so, what do they say?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
1
Republic of the Philippines
Department of Education
REGION XI – DAVAO REGION
SDO - DIVISION
NAME OF SCHOOL
ADDRESS
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 much time
and effort into solving problems?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
12. What type of help do you want?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
1
Republic of the Philippines
Department of Education
REGION XI – DAVAO REGION
SDO - DIVISION
NAME OF SCHOOL
ADDRESS
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 were the circumstances that brought the counselee to the interview?
__________________________________________________________________________________
_________________________________________________________________________________
_
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Counselor’s Notes:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
1
Republic of the Philippines
Department of Education
REGION XI – DAVAO REGION
SDO - DIVISION
NAME OF SCHOOL
ADDRESS
ANNEX C
COUNSELING PLAN
Name of Counselee: ________________________________
Overall Goals: (case to case basis)
1.
2.
SESSION # & SPECIFIC GOAL INTERVENTION
DATE
Prepared by:
____________________________________________
Signature over printed name of Guidance Counselor
1
Republic of the Philippines
Department of Education
REGION XI – DAVAO REGION
SDO - DIVISION
NAME OF SCHOOL
ADDRESS
ANNEX D
CASE NOTES TEMPLATE
Name of Counselee: _________________________Session No.: _____Date: ___________
Topics discussed during
the session
How the session is
related to the counseling
plan
How the counseling plan
goals and objectives are
being met
Interventions and
techniques used during
the session and their
effectiveness
Counseling observations
Progress or setbacks
Signs, symptoms and any
increase or decrease in
the severity of behaviors
as they relate to the main
concern
Homework assigned,
results and compliance (if
there’s any)
The counselee’s current
strengths and challenges
1
Republic of the Philippines
Department of Education
REGION XI – DAVAO REGION
SDO - DIVISION
NAME OF SCHOOL
ADDRESS
