SAINT ROSE OF LIMA SCHOOL, INC.

Capitol Heights, Villamonte, Bacolod City

Negros Occidental, Philippines
P.O Box 446, Tel No. 434-5885
strose_oflimaschool@yahoo.com/ stroseoflima50@gmail.com

Intake Interview Form

Date: ______________________________

Student’s Name: ________________________________________________

Referral Initiated by: ____________________________________________

STUDENTS INFORMATION:

Date of Birth: _____________________________________

Address: ___________________________________________________________________

Mother’s Name: ____________________________________ Occupation: ____________________

Father’s Name: _____________________________________ Occupation: ____________________

How many siblings do you have? __________________________

Parents Consulted? Yes ( ) No ( ) School Principal Consulted? Yes ( ) No ( )

OBSERVATION/ COMMENT:

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FOLLOW UP SCHEDULE:

Date: _______________________________________________________________________________

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Ms. Nikka Irah G. Camarista, RPm.

Guidance In-charge