Individual Inventory Form PDF

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Summary

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Description

RTU-SS-GCC-F-005

Rizal Technological University

CONTROL #_____-_____-______

Cities of Mandaluyong & Pasig 534-82-67

GUIDANCE AND COUNSELING CENTER

Individual Inventory Form

RECENT 2X2 PHOTO WITH BLUE BACKGROUND

COURSE:________________________________ Please fill up the following information below. Rest assured that all information will be treated with confidentiality. Thank you for your cooperation. PERSONAL INFORMATION Name:___________________________________________________________________Nickname:_______________________ Present Address: ________________________________________________________________________________________ Provincial Address: ________________________________________________________________________________________ Date of Birth: _____________ Place of Birth: _______________ Birth Order: _______________ Number of Siblings: _________ Age: _________ Gender: ____________ Civil Status: ________________ Religion: _____________ Nationality: ____________ Home Phone No. _________________________ Mobile No.: ___________________ Email Add: _________________________ Weight: _________________________________ Height: ______________________ Blood Type: ________________________ Hobbies/Interest: __________________________________________________________________________________________ Talents: _________________________________________________________________________________________________ In case of emergency, please notify: ____________________________________________ Relationship: ___________________ Address: ________________________________________________________________ Contact No. ______________________ FAMILY BACKGROUND Father

Mother Name Age Highest Educational Attainment Occupation Average Income per Month Contact Number / s

Status of Parents Married and living together Living in (not married) Separated Father is with another family Mother is with another family

Legally separated Mother (Widow) Father (Widower)

ACADEMIC INFORMATION Level Elementary Junior High School Senior High School Track:__________________ Strand: _________________

Name of School

Year Graduated

Awards Received

Subjects interested to: ______________________________________________________________________________________ Organization Membership: __________________________________________________________________________________ How is your studies financed? _______________________________________________________________________________ Is your present course / program your personal choice? Yes No

RIZAL TECHNOLOGICAL UNIVERSITY

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EFFECTIVITY: SEPTEMBER 1, 2015

RTU-SS-GCC-F-005

If no, A. Who influenced you? _____________________________________________________________________________ B. How do you feel about the course not being your first choice? _____________________________________________ _________________________________________________________________________________________________ C. What is your personal choice? ______________________________________________________________________ Why did you choose to enroll in RTU? Quality Education Free Tuition Fee Competitive Faculty Members Good facilities Proximity and accessibility Good reputation Recommended by friends, relatives, etc. Performance in the licensure examination Others, please specify: _________________________________________________________________________ What other school do you consider? JRU PUP UMAK

STI ABE ARELLANO AMA EARIST PNU Others, please specify__________________________

BEHAVIOR INFORMATION Check if you ever experience the following concerns: Bullying Suicidal thoughts Suicidal attempts Panic attacks Anxiety Depression Self / Anger Management Issues Recurring negative thoughts Low self-esteem Poor study habits Poor in decision making Impulsivity Poor sleeping habits Loss of appetite Over-eating Poor hygiene Withdrawal / Isolation Family problem Other relationship problems Alcohol addiction Gambling addiction Drug addiction Computer addiction Sexual harassment Sexual abuse Physical abuse Verbal abuse Pre-marital sex Teenage pregnancy Abortion Extra marital affairs RIZAL TECHNOLOGICAL UNIVERSITY

When did it happen?

Does it still bothering you? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

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No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No

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RTU-SS-GCC-F-005

PREVIOUS PSYCHOLOGICAL CONSULTATIONS Have you consulted a PSYCHIATRIST before? Yes No If YES, for what reason? ___________________________________________ When? _________________________________ Have you consulted a PSYCHOLOGIST before? Yes No If YES, for what reason? ___________________________________________ When? _________________________________ Have you consulted a COUNSELOR before? Yes No If YES, for what reason? ___________________________________________ When? _________________________________ PERSONAL DESCRIPTION (Tell something about yourself) _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

I hereby affirm that all information supplied herein is complete and is accurate and may be verified against original documents.

___________________________ Student’s signature

RIZAL TECHNOLOGICAL UNIVERSITY SEPTEMBER 1, 2015

___________________________ Date Accomplished

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