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REKOD SELIAAN B3

REKOD SELIAAN KAUNSELOR
MAKLUMAT DIRI

Nama : __________________________________________

Tingkatan : __________________________________________

No.KP : __________________________________________

Alamat : __________________________________________

___________________________________________

No.Telefon : ___________________________________________

PENYALAHANGUNAAN BAHAN

1. Tarikh / Bulan / Tahun mula mencuba rokok :
_____________________________

2. Bilangan rokok yang dihisap dalam sehari:
_____________________________

3. Tarikh akhir merokok :
_____________________________

4. Jenis dadah / inhalan yang dicuba :

Heroin Morfin Syabu
Ganja
Gam Arak Ubat Batuk Lain-lain

Pelajar lain yang anda tahu pernah mencuba dadah : ________________________________________________________________________ 10. Mengapa anda mencuba dadah : _________________________________________ _________________________________________ 9. Pernah anda disiasat oleh polis ? Ya tidak .kali mencuba Tarikh mula Tarikh akhir Dadah/Inhalan hingga mencuba mencuba sekarang Heroin kali Morfin kali Syabu kali Ganja kali Gam kali Arak kali Ubat Batuk kali Lain-lain kali 5. Dengan siapa anda mencuba : _________________________________________ 6. Dari mana di dapati bekalan : _________________________________________ 8. REKOD SELIAAN B3 Jika Lain-lain sila nyatakan : __________________________________ Bil. Di mana tempat mencuba : _________________________________________ 7. Setakat ini berapa jumlah wang yang digunakan membeli dadah / inhalan ? ________________________________________________________________________ 11.

1 Tarikh : _________________________________________ 12. Sesi Pertama Kaunseling Selepas Ujian Urin : ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________ 2. Sesi Selepas 3 Bulan Pertama Menghadiri Sesi Kaunseling / PIP : ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ . REKOD SELIAAN B3 ( jika ya nyatakan sebabnya ) _______________________________________________ ________________________________________________________________________ ________________________________________________________________________ 12.2 Keputusan : positif negatif ULASAN KAUNSELOR 1. Keputusan ujian air kencing 12.

REKOD SELIAAN B3 ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________ 3. Sesi Selepas 6 Bulan Pertama Menghadiri Sesi Kaunseling / PIP : ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________ 4. Sesi Selepas 1 Tahun Pertama Menghadiri Sesi Kaunseling / PIP : ______________________________________________________________________________ ______________________________________________________________________________ .

Penyertaan dalam aktiviti yang dianjurkan oleh pihak sekolah ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ . Kekerapan mengadaakan pertemuan dengan pihak sekolah B ISU Tempat Tarikh Catatan il 2. REKOD SELIAAN B3 ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________ KOMITMEN IBUBAPA 1.

REKOD SELIAAN B3 ________________________________________________________________________ 3. Pandangan secara umum terhadap ibubapa / penjaga klien ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ MAKLUMAT PEMANTAUAN BI TARIK MAS JENIS TINDAKAN/CAT TEMPAT L H A KAUNSELING ATAN .

………………………… . REKOD SELIAAN B3 TANDATANGAN KAUNSELOR PENGESAHAN PENGETUA …………………………………… ……….