GUIDENCE AND COUNSELING FORM

Name of Mentor: ….………………………………………………………………………………………………

Name of Student: ….………………………………………………………………………………………………

Type of counseling: Personal/Educational/Behavior- guidance and counseling

Counseling Session No: …………….. Day:…………..…Date: ……………….. Time:…………..
……..Venue:……………….. Duration……….…….Academic Year: 20…….
Batch: GNM – I/II/III Year: …………………………OR P.B.B.Sc. – I / IIYear : ……………………………
Reason of counseling:

1. Routine:…………………………………………………

2. Student Initiated:………….……………………………..

3. Teacher initiated:……..………………………………….

4. Other reason:……………………………………………..

Objectives of session:

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4. ………………….…………………………………………………………………………………………

Assessment of needs of student:

Issues related to the Institute: Issues regarding clinical assignments, adjustment issues, internal exams,
methods of teaching, approach of teacher towards students, Basic facilities in hostel and college, food quality in
canteen, library facilities, hospital duties or any other issue etc.

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Academic issues: (e.g., Exam phobia, exam related anxieties, study skills/habits, low grades in exams,
attendance, learning difficulties, decision-making, problem-solving, goal setting, and transitions/adjustment to
new situations).

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Family issues of student: (e.g., Domestic violence, divorce, separation, clash, conflict, death, loss, migration,
RTA incidence with family members etc.)

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Financial issues: (e.g. stress related to lack of money for the basic expenses, education loan, payment of tuition
fees, any other fees, hostel fees, canteen fees etc).

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Issues related to peers/friends(i.e. isolation, discrimination, conflicts, rumors, bullying, verbal abuse, no team
work, adjustment issues etc.)

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Physical health issues:

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Psychological health issues i.e. Homesickness,unusual sadness, loss of interest, fear of failure, low self-esteem,
inferiority complex, feels demotivated, stressors, anxiety issues, impaired attention, lack of study habits, lack of
planning of routine, physical issues, personal relationship issues etc.

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REMEDIES: PLAN OF ACTION:

1.Summary of issues if student:

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2.Solutions obtained from student:

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3.Possibleadvised by the mentor:

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Feedback of Mentor:

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Feedback of student:

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Follow up findings: Report (progress/regress)of student:

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Detail of next counseling session:

Day: …………………………Date:……………………. Time:………………….. Venue: …………………..…..

Objective:

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Signature of Student Signature of Mentor

Date: / / Date: / /