MALLIG NATIONAL HIGH SCHOOL-ANNEX
Mallig, Isabela
GUIDANCE OFFICE
PERSONAL DATA INVENTORY
DIRECTION: Please complete this inventory as accurately and honestly as you
can. The purpose of collecting this information is to be of assistance to you
in making choices and decisions. All information which you provide about
yourself will be treated confidentially.
NAME: _________________________________ Date: __________________
Birth date: _____________________ Birth Place: _________________
Address: ______________________________ Tel/cell Phone No.___________
Year & Section: _______________________ Sex: ___________________
Boarding house: _____________________________________________
Name of Landlord/landlady: __________________________________
Previous School Attended: ___________________________________
Outstanding Activities, Honors, awards (if any):_______________________
Mother’s Name: __________________________________________
Age: __________________ Occupation: _____________________
Father’s Name: __________________________________________
Age: __________________ Occupation: _____________________
Parent’s married: ______________________ Separated: ___________________
Parent’s not married: ____________________________
Mother/Father Remarried: ____________________________
Name of step-parent or guardian (if any):______________________________
Address: _____________________________ Age: _______________
Occupation: ___________________________
Sample Guidance Forms- 1
Name of brothers/ sisters studying here at Mallig National High School-Aannex
(Indicate year and section)
Name Year & Section
_______________________ _______________________
_______________________ _______________________
_______________________ _______________________
_______________________ ____________________
Indicate your Sibling Position: _______________________________________
SCHOLASTIC DATA:
A) Elementary school graduated ___________________________________
Date Graduated: ____________________ General Average: ____________
TEST RECORD:
Date Kind of Test Score Rank
_____________ ___________________ ____________ ___________
_____________ ___________________ ____________ ___________
_____________ ___________________ ____________ ___________
_____________ ___________________ ____________ ___________
VOCATIONAL PLANS:
List the occupation which you would like to make a living
______________________________ _____________________________
______________________________ _____________________________
School subject you like best:
______________________________ _____________________________
______________________________ _____________________________
School subject you like least:
______________________________ _____________________________
______________________________ _____________________________
Sample Guidance Forms- 2
CO-CURRICULAR ACTIVITIES:
Indicate the interest group to which you wish to belong.
(Please check)
_________ Sports Club
_________ Home Arts Club ______ Social Studies Club
_________ Religious Club ______ English Club
_________ Civic Awareness/Service Club ______ Filipino Club
_________ Math/ Science ______Others
EMOTIONAL REACTIONS:
______ Shy ______ Submissive _____ Confident
______ Friendly ______ Studious _____ Jealous
______ Nervous ______ Cheerful _____ Aggressive
______ Patient ______ Irritable _____ Unhappy
______ Stubborn ______ Lazy Fatigue
CHECK PROBLEM AREA IN WHICH YOU ENCOUNTER MUCH DIFFICULTIES
_______ Teacher Student Relationship
_______ Financial Difficulty
_______ Boy-Girl relationship
_______ Study habits
_______ Parent-child relationship
_______ Adjustment to school
_______ Boarding House
_______ Health Problem (Specify)
_______ Career choice
What is the highest level of education you expect to finish
(Check your choice)
_______ Technical/College
_______ Doctoral Degree
_______ Master’s Degree
_______ No intention to finish Degree
Briefly state your reason(s) why you enrolled here at Mallig National High
School-Annex
Sample Guidance Forms- 3
Questions:
1. Do you experience any problem or difficulty now?
_________________________________________________________________
2. If yes, describe your problem briefly:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
________________________________________________________________.
3. Would you like to talk over your difficulty to the guidance
counselor? ___________________________________________
4. Whom do you like to talk with? __________________________
Sample Guidance Forms- 4
Mallig ational High School-Annex
Mallig, Isabela
GUIDANCE OFFICE
FAMILY BACKGROUND FORM
Name:
Surname Given Name Middle Name
Birthday: ___________________________________
Birthplace: _________________________________
Address: ____________________________________
A) Paste your family picture including all the members and describe each.
B)
1. My father is ___________________ who works in _______________
And my mother is _________________ who works in _____________
They a) _____ live together
b) _____ are separated
c) _____ deceased (For M)
d) _____ remarried (For M)
e) _____ working abroad (Father, Mother or both)
2. I wish my dad is
_________________________________________________________________
Sample Guidance Forms- 5
3. I wish my mom is
_________________________________________________________________
4. I wish our family is
_________________________________________________________________
C)
1. My happiest moment with my family is when
_________________________________________________________________
2. Our saddest moment as a family is when
_________________________________________________________________
_________________________________________________________________
3. If luck will turn to my favor, I wish Dad and Mom will be
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
4. My greatest fear for our family is
_________________________________________________________________
D). Represent your family by drawing your favorite family activity
Sample Guidance Forms- 6
Mallig National High School-Annex
Mallig, Isabela
GUIDANCE OFFICE
PRE- COUNSELING FORM
Name: __________________________________________________________________
Surname First Name M.I.
Address: ____________________________________
Year $ section: _____________________________
Referred by: ________________________________
Chief Reason/s for referral:
___________________________________________________________
___________________________________________________________
__________________________________________________________.
Time Started: _______________________________
Date of Counseling: _________________________
Student’s Problem:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Summary of the interview:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Steps taken to assist the student:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Date of next scheduled interview: _____________________________
Time ended: _____________________________
____________________________
Guidance Coordinator
Sample Guidance Forms- 7
Mallig National High School-Annex
Mallig, Isabela
GUIDANCE OFFICE
FOLLOW-UP CUONSELING FORM
Name: _________________________________________________________________
Surname Given name M.I.
Year $ Section: ________________ Date last counseled:_________________
Time started: __________________ Follow-up No. _______________________
Student’s Problem:
_________________________________________________________________
A) BACKGROUND:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_______________________________________________________.
B) ASSESSMENT OF PROGRESS OF STUDENT:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
____________________.
C) STEPS TAKEN TO ASSIST THE STUDENT:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
____________________________________________________________.
DATE OF NEXT SCHEDULED INTERVIEW: _______________________________
DATE: _________________________
_______________________
Guidance Coordinator
Sample Guidance Forms- 8
Mallig National High School-Annex
Mallig, Isabela
GUIDANCE OFFICE
HOME VISITATION REPORT FORM
Name of Parent/Guardian: ________________________________________
Name of Child/Student: __________________________________________
Year $ Section: __________________________ Date: ________________
PURPOSE OF HOME VISITATION:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
______________________________________________________________.
SUMMARY:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_______________________.
ACTION TAKEN:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
______________________________.
RECOMMENDATION/S:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_______________________
Guidance Coordinator
Sample Guidance Forms- 9
Mallig National High School-Annex
Mallig, Isabela
GUIDANCE OFFICE FEEDBACK SLIP
Date:_______________
ADVISER: _____________________________
Kindly give us your comments concerning the attendance, class standing
and behavior of ________________________________________,
a student in your class _________________________.
We will appreciate it very much if you will hand this paper back
at the office the soonest time possible.
________________________
Guidance Coordinator
Comments:
1. Attendance _____________________________
2. Class Standing __________________________
3. Behavior in class _______________________
_______________________
Adviser’s Signature
Received by: ___________________
Date Received: _________________
Sample Guidance Forms- 10
Mallig National High School-Annex
Mallig, Isabela
GUIDANCE OFFICE
REFERRAL SLIP
___________________
Date
Name of Student: ________________________________
Year $ Section: _________________________________
Purpose of Referral: ____________________________
State the nature of problem: __________________________________________
_____ Psychological Testing
_____ Career/ Vocation Counseling
_____ Orientation Service Assistance
_____ Information Service Assistance
_____ Educational Placement assistance
_____ Others
_____________________
Name
_____________________
Designation
Sample Guidance Forms- 11
Mallig National High School-Annex
Mallig, Isabela
GUIDANCE OFFICE
NOTICE ON COUNSELING CASES
________________
Date
Dear Parents,
Please be informed that your child was referred to the Guidance Office
for guidance/counseling due to ____________________________.
May I therefore, request that you come to the Guidance Office on
________________ so that we could further discuss your child’s concern.
Thank you.
Very truly yours,
___________________
Guidance Coordinator
Sample Guidance Forms- 12
Mallig National High School-Annex
Mallig, Isabela
GUIDANCE OFFICE
CALL SLIP
Miss/ Mr. __________________,
Greetings!
You are requested to come to the Guidance Office
on _________________ at _____________ a.m./p.m.
______ Counseling
______ Follow- up
______ Testing
Please do not fail to come. Thank you.
Yours truly,
________________________
Guidance Counselor
Mallig National High School-Annex
Mallig, Isabela
GUIDANCE OFFICE
CALL SLIP
Miss/ Mr. _______________,
Greetings!
You are requested to come to the Guidance Office
On _______________
At _______________a.m. / p.m. for:
______Counseling _____ Follow-Up
_____Testing
Please do not fail to come. Thank you.
Yours truly,
______________________
Guidance Counsel
Sample Guidance Forms- 13
Mallig National High School-Annex
Mallig, Isabela
GUIDANCE OFFICE
COUNSELING REPORT
CONFIDENTIAL
Name: ____________________________________ Date: _________________
Age: _________ Year & Section: _________________ Sex: ____________
Sibling Position: ___________________ Religion: ___________________
PRESENT CONDITION:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___________________________________
CONCERN/ PROBLEM
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
________________________________
ATTITUDE/S TOWARDS PROBLEM
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___________________________________
RECOMMENDATION/INTERVENTION
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_________________________
Notes:
_____________________________________________________________________________
_____________________________________________________________________________
___________________________________________________________.
Sample Guidance Forms- 14
Mallig National High School-Annex
Mallig, Isabela
Name of Activity: ________________________Venue: ___________Date:____________
Year §ion: _________
Directions: Please read each statement in the questionnaire and check the number
that corresponds to your answer.
Scale: 5- Very strongly agree 4- Strongly agree 3-
Agree
2- Moderately Disagree 1- Strongly disagree
Items 5 4 3 2 1
1.The objectives of the activity were clear and specific.
2.There was evidence of adequate planning before this activity
was undertaken
3.The school policies, rules & regulations were manifested in
the behaviors of the students.
4.The venue’s conduciveness contributed in the realization of
the objectives of the activity.
5.The facilities were convenient.
6.The activities were appropriate, relevant and helpful in my
growth & development.
7.Quality of participation of the students.
8.Provision was made for acquainting students with
administrative and service personnel.
Note: item 8 is intended for orientation activity only.
Please write your comments and suggestions below.
A) Good points
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
___________________________.
B) Weak points
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
___________________________.
C) What would you suggest/recommend to improve the activity?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
____________________________________.
Sample Guidance Forms- 15
La Salette of Ramon
Ramon, Isabela
Seminar on: _______________________Date:______________Venue:_________________
Direction: kindly give your honest assessment about the seminar on the bases
of the factors enumerated below. Put a check on the column that
corresponds to your assessment.
5- Excellent 3-Good 1-Poor
4-Very good 2-Fair
Items Rating
1 2 3 4 5
1.Attainment of the objectives of the seminar
2.Effectiveness of the speaker/s
3.Timeliness of the topic
4.Time schedule management
5.Quality of participation of the participants
6.Venue of the seminar
Please answer the following questions.
1. What follow-up activities would you like to recommend?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
__________________.
2. Are there any comments which you would like to make?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_____________________.
Sample Guidance Forms- 16
