NORTHERN CEBU COLLEGES,INC.

Sor Dorotea Rubio St. cor. San Vicente Street

6010 City of Bogo, Province of Cebu, Philippines Region VII, Central Visayas

STUDENT COUNSELING REPORT

This counseling report will be made part of the following student’s file.
Student Name: ______________________________________________ Date: ___________________________________
Person Issuing Counseling: ____________________________________ Title: ___________________________________

INFORMATION ABOUT THE PERSON INVOLVED IN THE INCIDENT

Full Name:

Home Address:
Student Employee Visitor Vendor
Contact Information: Facebook Account:

INFORMATION ABOUT THE INCIDENT

Date of Incident: Time: Police Notified Yes No

Location of Incident
Description of Incident:

Has the student been warned about this behaviour prior to this incident: Yes No If no, how many times?:
The following offense has occurred to the serious or even extreme offenses that demands urgent and special
sanctions:___________________________________________________________________________________
Explanation:
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Follow up: (include specific expectations, clearly defined positive behavior, actions that will be taken if the behavior
continues, dates of future counselling sessions, etc.):
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NCCI Personnel (Printed): Yzel M. Senining
Title: ________________________________
Signature: ________________________________
I have read this notice, have spoken with my guidance counselor, and have had a chance to discuss this. I understand
this report and agree to abide by the rules of the College and the program.
Student Name (printed): Aimee T. Pajota
Signature: _________________________________________
Comments:
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I have reviewed this counselling record.
Coordinator: ___________________________ Date: ________________
Medical Director: _______________________ Date: _________________
Comments:
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