GUIDANCE AND COUNSELING SERVICES
STUDENT’S PERSONAL DATA SHEET
The Guidance and Counseling Services (GCS) observes STRICT CONFIDENTIALITY on the personal information shared in this form according to the ethical principles of confidentiality and in compliance with the Data Privacy Act. However, please take note that the information will be disclosed on the following circumstances:
1. Threat on the life of the client (e.g. attempt to commit suicide, victim of abuse)
2. The client can cause danger to the lives and health of other people.
Moreover, information may also be given to agencies (e.g. DSWD, Police, Women and Children Protection Unit, Rehabilitation Unit Hospitals and other health providers) that can facilitate or address client's need and situation.
Instruction: Please provide honest response to the information needed. Rest assured that data gathered will be treated with utmost confidentiality in accordance with Data Privacy Act.
PERSONAL BACKGROUND
Course/Track:
Major/Strand:
Grade/Year Level:
First Name:
Gender:
Date of Birth:
/
/
(month)
(day)
(year)
Age:
Middle Name:
Place of Birth:
Last Name:
Civil Status:
Single
Married
Widowed
Divorced
Separated
Religion:
Contact Number:
E-mail Address:
Permanent Address:
(street)/
(brgy)/
(city)/
(province)
Present Address:
(street)/
(brgy)/
(city)/
(province)
School Last Attended:
Location of School:
Previous Course/Grade:
FAMILY BACKGROUND
Name of Father:
Age:
Contact No:
Occupation:
Educational Attainment:
Name of Mother:
Age:
Contact No:
Occupation:
Educational Attainment:
Parents’ Permanent Address:
********
Husband/Wife (If Married):
Contact No:
Occupation:
Educational Attainment:
********
Name of Guardian (if applicable):
Age:
Contact No:
Occupation:
Pls. continue on the back page →
OTHER INFORMATION
1. Why did you choose this course/program?
2. How would you describe your family? Please put a check (/) mark on the space provided.
a family with harmonious relationship among family members
a family having conflict with some family members
a family with separated parents
a family with parents working abroad
others, pls. specify
3. Where do you live right now? Please put a check (/) mark on the space provided.
at home
boarding house
relatives
friends
others, pls. specify
4. Describe your living condition. Please put a check (/) mark on the space provided.
good environment for learning
not-so-good environment for learning
5. Do you have any physical/health condition/s?
No
Yes, pls. specify
6. Have you undergone intervention/treatment with a psychologist/psychiatrist?
No
Yes
CHECK THE SEMINARS/ACTIVITIES YOU WANT TO AVAIL FROM THE GUIDANCE & COUNSELING SERVICES
Adjustment (dealing with people, handling pressures, environment, class schedules, etc.)
Building Self-Confidence
Developing Communication Skills
Study Habits
Time Management
Tutorial with Peers (Please specify the subject/s)
others, pls. specify
AWARDS AND RECOGNITION
I hereby certify that all entries on the form are true and correct. I also agree to allow GCS to use the information/data for research purposes.
SIGNATURE OVER PRINTED NAME
