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ANNEX E - Counselee's Data - Confidential

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86 views2 pages

ANNEX E - Counselee's Data - Confidential

Uploaded by

ilynjinky.sapalo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ANNEX E

COUNSELEE’S DATA
A. Personal Information

Name:_______________________________________________________________________
Grade Level & Section: ________________________ School:___________________________
Birthday: _______________________________ Age: _______ Birth Order: ________________
(Month/Day/Year)
Address: _____________________________________________________________________
Contact Number: ___________________________ Email Address: ______________________
Gender: ( ) Female Nationality: ( ) Filipino
( ) Male ( ) Foreigner, please 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 P10,000.00
( ) P10,000.00 – 20,000.00
( ) P 20,000.00 – 30,000.00
( ) above P30,000.00
Parent’s Relationship Status
( ) Married and Living Together
( ) Married but Separated
( ) Both with other partners ( ) Not Married
( ) Father/Mother with another partner ( ) Deceased, please specify
____________________
( ) Both without parents
Siblings
(Use the back portion if necessary)

Name Age Educational Attainment Occupation


_____________________ _____ ____________________ ______________
_____________________ _____ ____________________ ______________
_____________________ _____ ____________________ ______________
_____________________ _____ ____________________ ______________

In case of emergency:
Person to contact: _______________________________________ Age:________________
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 or 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)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Counselee’s Signature over printed name Date

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