Republic of the Philippines

Department of Education
Region 02
ALICIA NATIONAL HIGH SCHOOL
Junior High School Department
Paddad, Alicia, Isabela

GUIDANCE AND COUNSELING OFFICE

CONFIDENTIAL COUNSELOR REFERRAL FORM

Name:_____________________________LRN:____________________Grade/Section:______________________
Parent/Guardian Name:________________________________Contact No.__________________________________
Date of Birth:________________________Student lives with:__________________________________________
Referred by: Teacher____ Parent:____ Self:____ Other:____
Reasons for Referal-Problems/concerns related to:
(Please check all that apply)
[ ]Dramatic change in behaviour [ ] Worries [ ] Daydream/fantasies
[ ] Grief [ ] Fears [ ] Sadness
[ ] Always tired [ ] Motivation [ ] Inattentive
[ ] Withdrawn [ ] Cries easily for age [ ] Self-Image/confidence
[ ] Non-Touchable/pulls away [ ] Nervous/anxious [ ] Perfectionist
[ ] Aggression/anger [ ] Swearing [ ] Fighting
[ ] Lying [ ] Bullying [ ] Disrespectful
[ ] Defiant [ ] Hurts self [ ] Impulsive
[ ] Overactive [ ] Easily distracted [ ] Chews (paper,clothes,hair)
[ ] Makes Odd Sounds [ ] Stealing [ ] Destruction of Property
[ ] Sexual Acting Out [ ] Peer relationships [ ] Social Skills
[ ] Personal Hygiene [ ] Family Concerns [ ] Academics
[ ] Absences [ ] Tardiness [ ] Work habits/Organizaton
[ ] Completion of Outputs [ ] Drop out risk [ ] Vices
[ ]Other
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Problem History:
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Actions taken by the person referring. (Please attach copies of any intervention attempted).
_________________________________________________________________________________________________
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Have you contacted parent/guardian about your concern? Yes/No Date:_____________________
Outcome of Parent Contact: ________________________________________________________________________

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Signature of Person Making Referral Date of Referral

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For Guidance Counselor Designate

Date received:_________________
Date of scheduled Meeting/Advising:______________________ Time:__________
Actual date and time of Meeting/Advising: _____________________________________________________
Follow up session schedule: _________________________________________________________________

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Student's Signature
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