Name (Optional): _____________________________________ Grade/Position: ______________

“SELF ASSESSMENT TOOL”

How can your guidance counselor help you?

1. I feel like I am having troubles in my
________ Academics
________ Love Life
________ Family Matters
________ Choosing my career
________ Relationship with Friends/Peers/Colleagues
________ Spiritual Growth
________ Work
________ Finances
________ Relationship with my Self
________ Others (Please Specify)
2. What program or activity would you like us to have in order to assist you in your
concerns?
________ Family Problems
________ Study Habits
________ Courting and Dating
________ Difficulty in making friends/social
________ Adjustments
________ Others (please specify)
3. Are your needs or concerns addressed effectively by your school counselor and
the office?
________ Yes
________ No
(If no please explain briefly) ____________________________________________.

Signature: _____________________________________