Matina Campus, Davao City

Phone No.: (082)227-5456 / (082) 224-5736

Telefax: (082)221-0460

CONSULTATION FORM
Name of Student: Date:
Course and Year: Class Time:
Current Address: Mobile No.:
Parent’s/ Guardian’s Name: Occupation:
Current Address: Mobile No.:
Student’s Personal Problem: (Confidentiality assured) Check ONLY ONE
( ) Academic Difficulty
( ) Boyfriend/ Girlfriend Details:
Instructions:
( ) Child/ Children
( ) Class Materials
1. To be filled up by
( ) Class Schedule
the Student only.
( ) Death of Love one
2. “None” and
( ) Family Problem
“Confidential” are
( ) Financial Problem
not accepted.
( ) Health Problem
3. Check ONLY ONE
( ) Home to School Distance
problem.
( ) Low Self-esteem
4. Write 3-
( ) Peers Problem
sentenced details on
( ) Personality
the right box.
( ) School Facilities
5. Required to fill all
( ) Study Habit
blanks.
( ) Teacher/ Personnel
6. Do not write
( ) Time Mismanagement
anything below.
( ) Unmotivated
( ) Work/ Job Problem
( ) Others (Specify)
DO NOT WRITE ANYTHING BELOW (except on Name and Signature)
Professor check only one and write 2-sentenced details.
( ) Change Class Schedule
Professor’s ( ) Consultation with Parents Details:
Remarks/ ( ) Dialogue with Boyfriend/ Girlfriend
Recommendation: ( ) Dialogue with Teacher/ Professor
( ) Find New Boarding House
1. To be consulted ( ) Find part-time work
to the Professor. ( ) Medical check-up
2. To be encoded by ( ) Referral to Guidance Counselor
the Discipline Head ( ) Referral to Religious Leader/ Priest
to SAP. ( ) Seek Scholarship
3. To be processed ( ) Seek Motivation
by the University ( ) Self-confidence
Guidance Counselor. ( ) Self-discipline
( ) Time Management
( ) Tutorials/ Study Regimen
( ) Others (Specify)

Submitted by: Consulted with:

________________________________ ________________________________
Student’s signature above printed name Class Instructor

Encoded to SAP by: Processed by:

________________________________ ________________________________
Discipline Head University Guidance Counselor – GSTC