ST.
PAUL COLLEGES FOUNDATION PANIQUI,
TARLAC INC.
Samput, Paniqui, Tarlac
INDIVIDUAL INVENTORY RECORD
Dear Students,
This is a questionnaire about yourself, your family, schoolwork, interest and traits,
your physical and emotional health. Some questions can be answered by writing YES or
NO or by putting a check ( √ ) mark. Other items can be answered by writing a few
sentences. Please fill out all items as honestly as you can. You may leave some items
unanswered if you feel they are not applicable to you. Rest assured that your answers will
be kept with strict confidentiality.
JANUARY 26 2022
PERSONAL DATA Year & Section: BSCS 1-J
NAME: DIVINA
Last Name
KAYE ANNE
First Name Middle Name
FEMALE Age: 20 Contact No.(s): 9706311018
APRIL 23 2001 Place of Birth: CUYAPO NUEVA ECIJA
FILIPINO Religion: CATHOLIC
Complete Home Address: PANIQUI TARLAC
FAMILY DATA
Is your father an alumnus of St. Paul? Yes ✓No
Is your mother an alumna of St. Paul? Yes ✓No
Number of Children in the Family: 5 Sibling Position: SECOND
Number of Boys: One Language/Dialect Spoken at Home:
TAGALOG
Number of Girls: Four Number of Helper/s at Home:
Marital Status of Parents: Parents Deceased: Father Mothe ✓Both Alive
r
✓Parents living together and here in the Philippines
Gender:
Date of Birth:
Nationality:
Parents living together but one working abroad Who?
Parents living together but both working abroad Where?
Parents separated without having each family
Parents separated with family/ies
* if belowFather's Address:
P60, 000.00 a CUYAPO
year NUEVA ECIJA Contact No. 9480232444
separated: Mother's Address: CUYAPO NUEVA ECIJA Contact No.
Living with, other than Parents with
Financial Status: whom?
Total Annual Income:✓Single Combined
P100, 001 to P150,000.00 a year
✓P60, 001 to P100,000.00 a yearAbove P 150, 000.00 a year
Rational Status:
a.The Person in the Family you are very close and confident with my father
b.How would you desribe your relation with: Other/s: specify
Father Very closeJust
✓ okBetter
than not Mother
Very closeJust okBetter than not
Sister/s Very closeJust okBetter than not
Brothers Very close Just ok Better than not
c. When you have problem/s does your family show that they care?
AlwaysSometimes Never Other/s: specify
SCHOOL WORK, ACTIVITIES, INTERESTS AND EXPERIENCES
1. Favorite Subject(s
) MATH 4. What are your present hobbies or interests?
2. Most Difficult Subject(s
) ENGLISH READING COMICS
3. Talents SINGING READING WATTPAD
WATCHING MOVIES
* What do you do during your free time?
read books, newspaper, magazines play computer games or video games
✓ watch TV shows, movies, music videos, etc. engage with sports
listen to music help in the house chores
play with other/s:
friends specify
*Do you play any musical instrument?
Yes ✓No if yes, what is it?
*Have you ever traveled before? Yes ✓No if yes, where?
*Have you ever stayed abroad? Yes ✓No if yes, where and how long?
5. Clubs: To what organization or club do you want to belong/join?
Class Organization ✓English-Filipino Club TLE Club
Other/s: specify
Math-Science ClubMakabayan ClubSSG
PHYSICAL HEALTH
A. My physical condition is: B. Emotional
✓very a.Are you happy most of the time? ✓Yes No
quite healthy, not bothered by
healthy
hardly satisfactory,
illness b.Are you bothered with problems? ✓Yes No
unsatisfactory, poor, differently
weak c.with whom do you usually talk about your
other/s:
abled problems?
specify
Father✓Older Sister Friends
MotherClassmate Grandprents
*Are you able to relax easily after Older brotherTeacher others
working
playing or Yes N d. Do you have many friends? Yes
hard? o No
e.Your companions/friends are
your own agefellow SRCS Students
younger than youfrom other school
older than you *what school?
CAREER INTEREST INFORMATION
I want to be a/an (a)_______programmer
Reason/s why you want to be a/an (a)_______________________ (b)____________________ (c)
Relatives ✓Scholarship grant Other/s: specify
______________________ Reason/s for choosing VNHS?
Who finances your studies?
Parents
IF TRANSFEREE
School Address:
Reason/s for transfering:
OTHER
Describe yourself as a A good person
INFORMATION
Special
person:talents you SINGIN and
posess: G WHEN YOURE STUCK, DONT GIVE UP! TRY SOMETGING
COMPLETE
NEW
Present problems/needs that is/are FAMILYFINANCIA
How do you
bothering want your Guidance CounselorL to
you? to guide
help you? me
State your motto/philosophy in life:
Unforgettable events in your life:
I hereby certify that the above information is true and correct. KAYE ANNE DIVINA _________________
Student's signature over printed name
Kindly send us back this form through your class adviser. Should you wish to discuss any
matter with us, feel free to see us at the Guidance & Counseling Office during your break/free
time.
Thank You,
Guidance
Counselor
TO BE FILLED UP ONLY BY THE GUIDANCE AND COUNSELING OFFICE STAFF
Psychological Test(s) / Dep Date of Results Notes
Ed Administration
National Test(s) Taken
a.
b.
c.
d.
e.
INTAKE INTERVIEW AND COUNSELING SESSION (use extra sheet if necessary)
Date:___________ Brief Description of Action Plan/
Problem Areas Purpose of
the problem Intervention
Counseling Type Referral
Referred by: Taken
Intake Interview Self
Teacher/s
Individual Family Principal
Group Studies Parents
Referral Friends Discipline Officer
Follow-up Financial Friends
____________ __________ ___________
Additional Note:
Follow-up Schedule (date/time):
Attending Guidance Counselor:
Date:___________ Brief Description of Action Plan/
Problem Areas Referred by: Purpose of
the problem Intervention
Counseling Type Referral
Taken
Intake Self Teacher/s
Interview
Individua Family Principal
lGroup Studies Parents
Referral Friends Discipline Officer
Follow-up Financial Friends
____________ __________ ___________
Additional
Note:
Follow-up Schedule (date/time):
Attending Guidance
Counselor:
INTAKE INTERVIEW AND COUNSELING SESSION (use extra sheet if necessary)
Date:___________ Brief Description of Action Plan/
Problem Areas Purpose of
the problem Intervention
Counseling Type Referral
Referred by: Taken
Intake Interview Self
Teacher/s
Individual Family Principal
Group Studies Parents
Referral Friends Discipline Officer
Follow-up Financial Friends
____________ __________ ___________
Additional Note:
Follow-up Schedule (date/time):
Attending Guidance Counselor:
Date:___________ Brief Description of Action
the Plan/ Intervention
Purpose of Referral
problem Taken
Intake Self Teacher/
Interview
Individu Famil s
Principa
al
Grou y
Studie l
Parent
p
Referra s
Friend s
Discipline Officer
lFollow- sFinancia Friend
up
___________ l
_________ s
__________
_
Additional _ _
Note:
Problem Areas Referred by:
Counseling Type
Follow-up Schedule (date/time):
Attending Guidance Counselor:
DATE OFFENSE/VIOLATION SANCTION/S BEHAVIORAL RESPONSE OF THE
STUDENT
1
2
3
4
5
S.Y. ____________ S.Y. ____________ S.Y. ____________ S.Y. ____________
Month No. of No. of No. of No. of No. of No. of No. of No. of No. of No. of No. of No. of
School Days Times School Days Times School Days Times School Days Times
Days Present Tardy Days Present Tardy Days Present Tardy Days Present Tardy
June
July
August
September
October
November
December
January
February
March
TOTAL
