Course/Strand & Year/Grade Level:
Gender:
Statement of Purpose:
The purpose of this assessment inventory is to determine the needs of the students. With your responses, you are helping us identify and design programs that would address your specific concerns to promote sound mental health and emotional well-being.
Rest assured that this will be treated with utmost confidentiality and in compliance with the Data Privacy Act.
Thank you.
Instructions:
The following are some of the needs experienced by people your age. Please help us identify which need you experience and whether you believe the Guidance Program should help you with these needs.
Use the following codes to indicate the extent to which it is important to you and please put a checkmark on the space provided.
| 1 |
- |
Not Important at All |
(NIA) |
| 2 |
- |
Somewhat Important |
(SI) |
| 3 |
- |
Moderately Important |
(MI) |
| 4 |
- |
Very Important |
(VI) |
| 5 |
- |
Extremely Important |
(EI) |
| NIA |
SI |
MI |
VI |
EI |
| 1 |
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3 |
4 |
5 |
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1. Know and understand myself better |
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2. Get rid of my fears |
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3. Manage my time |
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4. Plan my Life |
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5. Develop self-confidence |
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6. Discover my talents and develop them |
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7. Improve my appearance |
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8. Learn more about the word outside |
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9. Get rid of personal vices/uncontrollable habits (drugs, alcohol, stealing, violence, smoking, sex, gambling, and computer addiction) |
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10. Others (pls. specify) |
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| B. Family Relationships |
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1. Improve my relationship with my siblings |
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2. Manage siblings in a parentless home |
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3. Develop the ability to discuss problems with parents |
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4. Balance between warring/separated parents |
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5. Teach parents how to handle their children effectively |
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6. Help parents manage stress/marital problems (pls. underline) |
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7. Live with relatives |
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8. Cope with the expectations/demands of parents |
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9. Relate with stepparent/step siblings (pls. underline) |
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10. Others (pls. specify) |
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| C. Social Relationships |
| 1. Develop skills for starting/maintaining friendships |
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| 2. Make myself attracted to others |
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| 3. Develop the ability to avoid being taken advantage of |
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Pls. continue on the back page →
| NIA |
SI |
MI |
VI |
EI |
| 1 |
2 |
3 |
4 |
5 |
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4. Know how to choose friends |
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5. Get rid of fear of social situations |
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6. Settle quarrels with/among friends |
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7. Handle boy-girl relationships |
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8. Handle peer pressure |
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9. Deal effectively with bullies |
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10. Others (pls. specify) |
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| D. Studies |
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1. Understand my lessons |
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2. Find time to finish assignments and socialize |
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3. Develop confidence in recitations and discussions |
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4. Talk to teacher about difficulty in understanding lessons |
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5. Balance between work at home and studies |
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6. Work with classmates on projects |
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7. Cope with financial demands of projects |
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8. Develop professionalism among teachers |
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9. Improve teaching effectiveness of teachers |
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10. Others (pls. specify) |
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| E. Specific Social Issues |
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1. Learn more about physical abuse |
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2. Learn more about sexual abuse/ harassment |
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3. Learn more about emotional and verbal abuse |
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4. Handle experiences of abuse (physical, sexual, emotional, and verbal) |
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5. Handle alcoholic/or drugs-dependent family member |
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6. Handle effects of disaster/crisis/calamities |
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7. Cope with losses (separation, abandonment, death, overseas work) |
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8. Deal with parents' extramarital affairs |
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9. Handle college life adjustments (pls. specify: _____________________) |
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10. Mental Health Issues: (Depression, Anxiety, Suicidal Ideation etc.) |
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11. Others (pls. specify) |
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Please feel free to write down any additional needs or concerns that you wish the Guidance & Counseling Services would address. Thank you.
I agree to let the Guidance and Counseling Services use the information/data from this form for research purposes.
Signature over Printed Name
