Page 110 - PARAMETER B

Membership in Organization during High School

Name of Organization Position Held
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State your goal in life: ________________________________________________________________________________
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Check the Problem Areas in which you usually find difficulty:
_____ Teacher-student Relationship _____ Financial Support
_____ Boy-Girl Relationship _____ Study Habits
_____ Parent-Child Relationship _____ Gaining Self-confidence
_____ Boarding House _____ Adjustment to school
_____ Career Choice Others: Specify ________________

If you have a problem now give a short description:
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Is your home a happy family? ______ Why? _________________________________________________
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To whom would you like to confide your problem? (Please Check)
_____ Guidance Counselor _____ Adviser _____ Dean _____ Others: (Specify)

Check which of the following Group Guidance Activities you would like to attend.
_____ 1. Overcoming shyness, nervousness, stage fright
_____ 2. How to manage your time
_____ 3. Proper spending of leisure or free time
_____ 4. Proper behavior with the opposite sex (ex. love, courtship, dating)
_____ 5. How to cope with financial difficulty
_____ 6. How to control anger and other negative behaviors
_____ 7. How to improve academic performance
_____ 8. Others: Specify ____________________________________________

Please check any of the following words which seem to describe you fairly:
_____ Active _____ Ambitious _____ Self-confident
_____ Not easily discouraged _____ Hardworking _____ Submissive
_____ Absent-minded _____ Systematic _____ Likable
_____ Often feel lonely _____ Serious _____ Easy going
_____ Good natured _____ Nervous _____ Impatient
_____ Impulsive _____ Quick-Tempered _____ Excitable
_____ Leader _____ Timid _____ Lazy
_____ Unemotional _____ Shy _____ Sociable
_____ Quiet _____Imaginative _____Original
_____ Witty _____ Calm _____ Dependable
_____ Reliable _____ Cheerful _____ Sarcastic
_____ Self-conscious _____ others: (Specify)

Your CP #: _________________
Facebook account name: ______________ (intended for tele-counseling)
CP # of Parents or Guardian: _________________
Email address:_____________________________

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Student’s Signature