For the High School Faculty

GUIDANCE REFFERAL FORM

Date _________________
To ______________________________
From ____________________________

I would like to refer:

Name ___________________________________
Gr. and Sec ____________________________
For the following reasons (pls. check your observation/s)

A. ( ) Behavioral/Social
___ sleeps/daydreams in class ___ shows difficulty in relating with
___ easily gets distracted classmates
___ acts impulsively ___ is often/absent
___ frequently complains about poor health ___ talks and distracts in class
___ refuses or cannot work by herself ___ too quiet, shy, and withdrawn
___ always has other complaints ___ demonstrates boredom or indifferent
with school work
B. ( ) Academic
___ participates poorly in class discussion
___ manifest difficulty in following instructions
___ shows lack motivation/ interest/ seriousness in studies
___ always fails to submit work on time
___ always obtains failing scores in tests

C. Others
Description ________________________________________________________________________________
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For the Guidance Counselor

PROGRESS REPORT
Date _________________
To ______________________________
From ____________________________
Name of Student (Referral) ___________________________________
Gr./Yr. and Sec ____________________________

Nature/ Reasons for Referral

____________________________________________________________________
Date Referred ___________________________
Action Taken
( ) Counseling
( ) Teacher Conference
( ) Parent Conference
( ) Referred to: Name_____________________________________
Position/ Specialization _________________________________

Comments/ Recommendations __________________________________________________________________

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__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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GCO F14