Republic of the Philippines

Region VII, Central Visayas

Division of Lapu-Lapu City
Science and Technology Education Center
Senior High School Department
Basak, Lapu-Lapu City

COUNSELING FORM
Disclaimer: This Counseling Form is not an official Guidance Form of the school whose logo is presented above. This form is rather designed and crafted for the purpose of a Counseling Simulation in compliance of the subject
Disciplines and Ideas in the Applied Social Sciences.

Important: Please provide the important information required. Rest assured, all information gathered are treated with much confidentiality. Thank you.
Miraña Danielle Christian P.
Name of Client: __________________________________ ____________________________________ ______
Family Name Given Name M.I.
18
Age: ________________________ MALE
Gender: __________________________ 09/15/02
Birthday: ____________________

Brgy.Mactan, kasanta,Lapu-lapu City

Address: ____________________________________________________________________________________________
Daniellechristianmirana@gmail.com 09297185357
Contact Details: Your E-mail: _________________________________ Your Phone Number: ____________________

Marissa P. Miraña (Mother) Edsel G. Miraña(Father)

Name of Parent/Guardian: ______________________________________________________________________________
Parent/Guardian knows about this: ___ YES ___ NO
Dear Client,
Warm Greetings!
May I extend my words of gratitude for the trust that you have afforded to me as your Counselor. As we go through with our counseling session, don’t be afraid
to speak about the troubles/challenges that you are going through. If by any means this counseling process will grant you the autonomy, then I lend you my ears
to listen, my heart to empathize and my mind to understand every details of the situation. After the session, trust me that whatever have transpired, it will be
treated with the sincerest confidentiality.
You are a blessing!

Love,
Your Guidance Counselor

I would appreciate if you could give me a brief history about the trouble/challenge that you are going through. Please write it below.

Ever since high school I only have this problem and it’s not being sure about my choices, like every time I have to
choose, fear of failure will always come to haunt me. Like I am doubtful about what I’m going to do with my life. I’m not
sure if this is the right choice. Which makes me less confident if given a chance to choose from something, like what if I
would regret this choice in the near future. So I guess that is all my problem, I can’t really make a decision by myself. It is
also the reason why I’d rather want to live alone, in order to avoid giving trouble to anyone. I also wanted live my life
alone, I don’t really care if I get married or not or have a family. Like for me it is just another problem in my life. The
point is, is it really a good action, is isolation good for me? I don’t really know, all I want is to end everything.

Agreement Notes from the Counselor

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Assessment: (To be filled-out only by the School Counselor)
Based on the counseling session, the undersigned wish to refer the challenge/trouble presented by the client to a _______________
citing the limitations and restrictions of my duties and responsibilities .

________________________________________ __________________________________ _____________________

School Counselor Name and Signature Client Name and Signature Date

CODE:
 Republic of the Philippines
Region VII, Central Visayas
Division of Lapu-Lapu City
Science and Technology Education Center
Senior High School Department
Basak, Lapu-Lapu City

Criteria intended for the Counseling Simulation

As Client Total As Counselor Total
Name of Presentation Disposition before- Overall Professional Counseling Comprehensive Use of
of Problem/ during-after the Display of Role Skills Relationship
Republic ofCounseling Skills,
the Philippines
Student Challenge session Performance 90 ( 30 ) )
( 30Region Methods & Techniques 90
( 30 ) (30 ) ( 30 ) VII, Central Visayas
( 30)
Division of Lapu-Lapu City
1. Science and Technology Education Center
Comment: Senior High School Department
Basak, Lapu-Lapu City

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 Criteria intended for the Counseling Simulation
As Client Total As Counselor Total
Name of Presentation Disposition before- Overall Professional Counseling Comprehensive Use of
of Problem/ during-after the Display of Role Skills Relationship
Republic ofCounseling Skills,
the Philippines
Student Challenge session Performance 90 ( 30 ) )
( 30Region Methods & Techniques 90
( 30 ) (30 ) ( 30 ) VII, Central Visayas
( 30)
Division of Lapu-Lapu City
15. Science and Technology Education Center
Comment: Senior High School Department
Basak, Lapu-Lapu City

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Overall Impression by the Teacher-Observer

Date: November 5, 2020 Signature over printed Name:

Criteria intended for the Counseling Simulation
 As Client Total As Counselor Total
Name of Presentation Disposition before- Overall Professional Counseling Comprehensive Use of
of Problem/ during-after the Display of Role Skills Relationship Counseling Skills,
Student Challenge session Performance 90 ( 30 ) ( 30 ) Methods & Techniques 90
( 30 ) (30 ) ( 30 ) ( 30)

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INSTRUCTIONS
** Please accomplish Form 1 (Guidance Form) and submit the same to your partner for analysis to prepare him/her in the
simulation.
** Be guided with the Criteria posted for the Counseling Simulation
**Please be guided in the pairing and schedule of the Counseling Simulation
1. DE LARA And SULLANO: 7:30-7:40 ( I will act as the Counselee based on your Guidance Form and you will be the Counselor.)
2. DAÑO AND DONAIRE: 7:40-8:00
3. CALAGUAS AND TUSIT: 8:00-8:20
4. ENGLIS AND TUBURAN: 8:20-8:40
5. IGOT AND TAMPUS: 8:40-9:00
6. MIRAÑA AND SALDUA: 9:00-9:20
7. SALUTILLO AND PACALDO: 9:20-9:40
8. SEÑAHON AND JURILLA: 9:40-10:00
9. ABRENICA AND INFANTE: 10:00-10:20
10. ABRIA AND IMPERIAL: 10:20-10:40
11. ALCANTARA AND HOBIENA: 10:40-11:00
12. BALABA AND GODIN: 11:00-11:20
13. CABATAY AND GASPAY: 11:20-11:40
14. DAGPIN AND EGOS: 11:40-12:00
**Please join the class on the scheduled time.
**Turn-on the cam during the duration of the Counseling Simulation.
**Follow the set-up below:
First 10 minutes Succeeding 10minutes
Student A- Counselee Student B - Counselee
Student B - Counselor Student A - Counselor
Note: Student A is the first person listed in the pairing while the second person listed in the pairing is Student B.