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Application Form For PMC Accreditation (Page 1 Only)

The document is an application form for accreditation as a pre-marriage counselor. It requests personal and work information from the applicant, including education, experience conducting pre-marriage counseling sessions, and training. The form has sections for previous work experience, training attended in the last three years, and describing counseling experiences and insights gained.

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Jeshella Roxas
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133 views3 pages

Application Form For PMC Accreditation (Page 1 Only)

The document is an application form for accreditation as a pre-marriage counselor. It requests personal and work information from the applicant, including education, experience conducting pre-marriage counseling sessions, and training. The form has sections for previous work experience, training attended in the last three years, and describing counseling experiences and insights gained.

Uploaded by

Jeshella Roxas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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DSWD-SB-GF-017 | REV 00 | 04 MAR 2022

Annex A
PMC Form_App
Republika ng Pilipinas
(Republic of the Philippines)
Kagawaran ng Kagalingang Panlipunan at Pagpapaunlad
(Department of Social Welfare and Development)
Region: VIII

Application Form for the Accreditation of Pre-Marriage Counselor

Instruction: Kindly fill-in the needed information.

Region: VIII Date: April 13, 2022


LGU (if applicable): LGU-Motiong, Samar

Status of Accreditation:

New Renewal

Status of Assessment:

1st Assessment Re-Assessment

A. Personal Information:

Name: AGNES B. LLAMADO Age: 45 Sex: Male Female


(Full Print)
Civil Status: Single Married Widow Separated Others, specify:___

Date of Birth: July 24,1976 Mobile No/Tel.No: 09177135638 E-Mail Add.: nezaodamall@gmail.com

Residential/Home Address: 62 San Simplicio St. Brgy. I-A Motiong, Samar.

Course: BS Social Work Post Graduate studies, if any: Masters in Public Management

B. Work Information (if applicable):

Name of Agency/LGU: Motiong, Samar_____________________________________________

Office Address: Brgy. I-A, Motiong, Samar___________________________________________

Position and Designation: MSWDO No. of mos./years in current position: 4 Years


No. of Years in Service: 23 No. of mos. / years as PM Counselor: 5 Years_

Total No. of PMC Sessions conducted and would-be-couples served for the past year: 270 ; 960

PAGE 1 of 3
DSWD Field Office VIII, Magsaysay Boulevard, Tacloban City, Philippines
Email: fo8@dswd.gov.ph website: https://dswd.gov.ph Telephone No. 321-3322
DSWD-SB-GF-017 | REV 00 | 04 MAR 2022

C. Previous Work Experience from Present to Past (Please use separate sheet when necessary)

Name of Agency Position/Designation Date


From-To

D. Training Courses/Seminars Attended related to PMC/Counseling for the last three (3)
years. (Start with the recent training/seminar attended. Please use separate sheet when necessary)

Title Date No. of Hours/ Duration Conducted/Organized by

E. Experience in providing Pre-Marriage Counseling/other form of Counseling Service/s


(Please use separate sheet when necessary)

1. Describe your most significant/difficult experience/s in providing counseling to


couples/clients, and how were you able to deal with this/these?

___________________________________________________________________
●

___________________________________________________________________
●

___________________________________________________________________
●

___________________________________________________________________
●

2. What were your insights/learning from this/these experience/s?

___________________________________________________________________
●

___________________________________________________________________
●

___________________________________________________________________
●

___________________________________________________________________
●

PAGE 2 of 3
Application Form for the Accreditation of Pre-Marriage Counselor
DSWD FIELD OFFICE VIII-STANDARDS SECTION
DSWD-SB-GF-017 | REV 00 | 04 MAR 2022

_____________________________
Signature over Printed Name
Applicant

PAGE 3 of 3
Application Form for the Accreditation of Pre-Marriage Counselor
DSWD FIELD OFFICE VIII-STANDARDS SECTION

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