New-HOME VISITATION-Forms-SDO-Batangas-portrait PDF

Republic of the Philippines
Department of Education
REGION IV-A CALABARZON
SCHOOLS DIVISION OF BATANGAS
Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

(043)722-1840 / 722-1796 / 722-1437 / 722-2675 / 722-1662
deped.batangas@deped.gov.ph
www.depedbatangas.org
GUIDANCE PROGRAMS:
ACTIVITY YEAR
PROGRAM PARTICIPANTS IMPLEMENTING ARM
TITLE CONDUCTED
Prepared: Approved by:
Signature over Printed Name Signature over Printed Name

Position Position

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ACCOMPLISHMENT REPORT
SY ________
I. PROGRAM TITLE: __________________________________________

II. RATIONALE
III. OBJECTIVES
IV. STRATEGIES/ ACTIVITIES
V. NO. OF BENEFICIARIES
VI. SCOPE
VII. SOURCE OF FUND
VIII. IMPACT
Prepared:
Signature over printed name
Position
Approved by:
Signature over printed name

Position

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(043)722-1840 / 722-1796 / 722-1437 / 722-2675 / 722-1662

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Home Visitation Form
Student's Name: MENDOZA, JOHN MICHAEL, J. Age: 13

Grade & Section: G7 - Masipag Adviser: Christian V. Marzo
1. Date of home visit? January 20, 2023
2 . Purpose of home visit?
3. Who was/were present?

4. What are the occupations of the
parents?
5. Are the parents living
together? How many are they in the family:
6. Are the family's basic needs being met (i.e. electricity, water, adequate food and clothing,
etc.)?
7. What issues were discussed at the

home visit?
8. Were any
recommendations/suggestions given to
parent /family?
9. What were they?
who is responsible for follow up?

10. Next steps
Action Target Date Responsible Person
Person Conducting Home Visit: ___________________________

Date: _____________________ Signature of Parents

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HOME VISITATION FORM
Name: _____________________________________________
MENDOZA, JOHN MICHAEL, J. Grade & Section: G7 - Masipag
Learner’s Reference Number: ___________________

107410140327 Age: __13__Sex: MALE
Contact Number: ____________________Class Adviser/Teacher: CHRISTIAN V. MARZO
Address: Roxas Subd. Lumbangan, Nasugbu Batangas Date: January 20, 2023
Purpose of Visit:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
____________________________________________.
Remarks:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________________.
___________________________________________
Name of Teacher who conducted the Home Visitation
________________________________________
Signature Over Printed Name of Person Visited
_________________________________________
Relationship to the Student
________________________________________________
Signature Over Printed Name of Barangay Representative
___________________________________________
Designation

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SUMMARY ATTENDANCE
S.Y. ____________
Year & Section:
Name of Students June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May Remarks
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Reported by:
Guidance Counselor
Verified by:
Adviser

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Name of School
Anecdotal Form
Pangalan: Petsa ng kapanganakan:

Ama: Tirahan:
Ina: Contact Number:
Grade 7
PAG-UUGALI SITWASYON SA PAMILYA
Grade 8

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Grade 9
SEKSYON GURONG TAGAPAYO

Grade 7
Grade 8
Grade 9
Grade 10

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Grade 11
Grade 12
SEKSYON GURONG TAGAPAYO

Grade 10
Grade 11
Grade 12

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ANECDOTAL RECORD
PERSON OBSERVED:
Date/Time Place Observer Violation Details of the Case Action Taken
Summary:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
______________________________________________

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SULAT SA MAGULANG
Petsa:_____________
o Unang Pabatid
________________________________ o Ikalawang Pabatid
________________________________ o Ikatlong Pabatid
________________________________
Minamahal na Magulang:
Ipinababatid po namin sa inyo na ang inyong anak na si ______________________________________ na nasa
baitang_________________ ng ___________________ ay:
________Nahuling ⃝nagplano, ⃝nagpasimula, ⃝nakilahok sa alitang ⃝ di-malubhang sakitan, ⃝ walang sakitan

(salita o sulat) ⃝malubhang sakitan.
________Hindi gumagalang sa awtoridad/kaninuman sa ⃝loob ⃝labas ng paaralan ⃝MALUBHA ⃝HINDI MALUBHA
________Nagsasabi ng mahahalay na salita.
________Nahuling ⃝Nagplano ⃝Nagsagawa ⃝Kasangkot sa ⃝pagnanakaw ⃝paninira ng pag-aari ng paaralan o
ninuman.
________Hindi nagbibigay galang sa watawat, logo at ID ng paaralan
________Hindi gumagawa ng takdang aralin/proyekto,⃝Hindi tumutupad ng mga gawaing pansilid-aralan
________Hindi nagsusuot ng takdang uniporme
________Mahilig maglagay at magsuot ng mga di angkop na palamuti sa katawan.
________May hindi magandang kaasalan.________________________________________________
________Lumiliban sa klase ng walang pahintulot at matibay na dahilan⃝Hindi nagsumite ng liham bagay sa pagliban
________Lumalabas ng walang paalam habang nagkaklase ang guro.
________Nagkacutting classes._____ beses
________Natigil/istambay sa mga palikuran o saan mang lugar sa paaralan sa oras na may klase.
________⃝Umuupo ⃝Pinupukpok ⃝Sinisipa ⃝Nagsusulat ng hindi kaayaaya ⃝ Naglalabas ng gamit na nasa loob ng
silid aralan.
________Nagkakalat at nagtatapon ng basura sa di tamang basurahan.
________⃝Nahiyaw ⃝Nasipol ⃝Maingay sa ⃝loob ⃝labas ng silid-aralan.
________Nahuling umiihi sa hindi tamang lugar
________Pumapasok ng late sa paaralan o klase_____
________Nakikilahok sa samahang di pinahihintulutan ng paaralan ⃝fraternity ⃝sorority.
________Pakikibahagi sa mahalay na gawain ⃝pananalita ⃝pagsulat ⃝pornograpiya-larawan o video ⃝public display
of affection).
________⃝Nagbabanta ⃝Nananakot sa kaninuman (salita, sulat, text, cyberspace, atbp).
________Nahuling ⃝nagdala ⃝nagbenta ⃝nagtatago ⃝nagbili ⃝gumamit ng mga nakamamatay at nakasasakit na
bagay ⃝paputok ⃝droga ⃝sigarilyo ⃝nakalalason na kemikal ⃝inuming nakalalasing sa loob at labas na sakop ng
paaralan
________Nahuling nagsagawa ng paghuhuwad ng papeles, lagda, sulat at iba pang mga kauri (project, takdang aralin,
activity, report card, mahahalagang papeles ).
________Nahuling nagsusugal
________Nahuling tumawid o tumalon sa bakod
________Nahuling nagcocomputer o nakatigil sa labas ng silid aralan at paaralan sa araw at oras ng may klase.
________May reklamo ng Pangbubully
Ang inyo pong tulong ay higit po naming kinakailangan, kaya pinakikiusapan po kayo na magsadya rito sa
paaralan at hanapin si Ginoo/Gng.______________________________ ⃝Gurong Tagapayo ⃝Prefect of Discipline
Officer upang atin pong mapag-usapan ang mga bagay na nabanggit tungkol sa inyong anak.
HUWAG PO SANA NINYONG IPAGWALANG BAHALA ANG PAALALANG ITO
PAALALA: 1. Bigyan lang ng pansin ang mga aytem na may tsek (√)
2. Ayon po sa Batas Pambansa 232 chapter 3,seks. 14(3) ay isinasaad ang tungkulin at responsibilidad ng
mga magulang na makipagtulungan sa pagpapatupad ng anumang gawaing pampaaralan.

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(043)722-1840 / 722-1796 / 722-1437 / 722-2675 / 722-1662
STUDENT’S INDIVIDUAL INVENTORY
I. PERSONAL INFORMATION
Name: __________________________________________________________ Nickname: _________________
(Surname) ( First Name) ( Middle Name)
Date of Birth: _________________ Place of Birth: ____________________________________________________

Age: ______ Sex: ______ Religion: _____________ Address: _____________________________________________
(House No.) (Street) (Brgy.) (Municipality) (Province)
Year and Section: Grade 7-____________ Grade 8-______________ Grade 9-____________ Grade 10-_____________
No. of children in the Family (including yourself): _________ _ No. of Brothers; _________ No. of Sisters: __________
Order of your Birth: ( ) First ( ) Middle ( ) Last ( ) Only ( ) Others specify: ________________________
The person in the family you are very close to and confident with : ( )Father ( )Mother ( )Brother ( ) Sister ( )Others_____________
How would you describe your relation with Father ( ) VERY CLOSE ( ) JUST OK ( ) BETTER THAN NOT ( ) NEVER
Mother ( ) VERY CLOSE ( ) JUST OK ( ) BETTER THAN NOT ( ) NEVER
Brother ( ) VERY CLOSE ( ) JUST OK ( ) BETTER THAN NOT ( ) NEVER
Sister ( ) VERY CLOSE ( ) JUST OK ( ) BETTER THAN NOT ( ) NEVER
Others ( ) VERY CLOSE ( ) JUST OK ( ) BETTER THAN NOT ( ) NEVER
Favorite Subject:________________________________ Most Difficult Subject:______________________________
Interest: __________________________________________________________________________________________
I want to be :_______________________________________________________________________________________
II. EDUCATIONAL BACKGROUND

Elementary School Graduated: _________________________________________________ LRN: _________________
School Year: ___________ General Average: __________ Honors/Awards Received:______________________________
III.FAMILY BACKGROUND
A. Parents:
Name of Father:______________________________ Name of Mother:_______________________________
(Surname) ( First Name) ( Middle Name) (Surname) ( First Name) ( Middle Name)
Age: _________ Occupation: ___________________ Age: _________ Occupation: ____________________

B. Educational Status:
1. Father
Elementary: __________________________________ ( ) Graduate ( ) Undergraduate:_____________
High School: __________________________________ ( ) Graduate ( ) Undergraduate:_____________
College: _____________________________________ ( ) Graduate ______________ ( ) Undergraduate
Others:___________________________________________________________________________________
2. Mother
Elementary: __________________________________ ( ) Graduate ( ) Undergraduate:_____________
High School: __________________________________ ( ) Graduate ( ) Undergraduate:_____________
College: _____________________________________ ( ) Graduate ______________ ( ) Undergraduate
Others:___________________________________________________________________________________
C. Financial Status:
1. My Father’s weekly Income: ____________________________Monthly:_____________________________
2. My Mother’s weekly Income: ____________________________Monthly:_____________________________
D. Marital Status of Parents:
____ Married ______ Church ________ Civil _______ Not Married
____ living together and here in the Philippines
____ Living together but one working abroad, who?___________________ where? _____________________
____ Living together but both working abroad, where?____________________________________________
____ Separate without having each a family
____ Separate with other families
I

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IV. SCHOOL MATTERS

ALWAYS USUALLY SOMETIMES RARELY NEVER
Initiates studying on his/ her own
Balances work and Leisure
Ensure that all assignments are completed and correct
Does not stop studying until he/she has mastered subject
matter
Does additional research
Mental Ability Test (High School Level) Result:
Do you fear to take test? Yes No
Do you want to visit the guidance office for counselling? Yes No
Do you welcome home visitation? Yes No

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ANNEX A
Statement of Confidentiality
Counseling services cater to the mental health and well-being of all

learners. The Guidance and Counseling Office recognizes that people are
faced with various life stressors that can interfere with their daily behavior
and functions. Counseling services are completely confidential.
There are a few exceptions or limitations to confidentiality in

counseling situations. The following are the conditions to be considered in
breaking the confidentiality in counseling:
a. If you are becoming an imminent danger to yourself and/or to others through

thoughts of suicide or threats to harm other people.
b. If there is a reasonable suspicion of emotional and/or physical neglect
and/or abuse including sexual abuse of a minor.
c. In rare cases, courts will be asking guidance counselors to testify about you.
Confidentiality Guidelines
Many people are concerned about the confidentiality of meeting with

a counselor. The following guidelines provide information about the nature
of our services.
The following are kept confidential:

a. that you are seeing a counselor;
b. all contact information, including your counseling schedules; and
c. the guidance counselor being the only person who has access to the
information discussed, unless you give written permission for specific
information to be shared.
Rights and Responsibilities of Client
You have the right to:
• be treated with respect and consideration;

• know that information you share during the counseling process is
confidential;
• discuss with your counselor any concerns or dissatisfaction you may have about
your counseling experience;
• refuse to complete any consent forms requested during the counseling process;
and
• ask for referral to another counselor.

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You are responsible for:
• treating the Guidance and Counseling Office personnel with respect and
consideration;
• maintaining the confidentiality of others in group counseling sessions (if
applicable);
• helping to make your counseling experience meaningful; and
• letting us know immediately about any concern(s) you may have with our
service.
By signing this, I have read, understood and agreed to the provisions

of this Statement of Confidentiality of the Guidance and Counseling
Office.
Parent’s Signature over printed name Date and Time

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ANNEX B
INTAKE INTERVIEW FORM
Name: :
Birth Date: Sex: Preferred Language:
We are concerned about how things are going for you. Our
session today will help us discuss what's going O.K. and what's not
going so well. Everything is confidential except for those that need to be
discussed with others in order to HELP you.
1. How would you describe your current situation? What problems are you
experiencing? What are your main concerns?
2. How serious are these matters for you at this time?

Very Serious Serious Not too serious Not serious at all
3. How long have you had these problems?

0-3 months 4 months to a year more than a year
4. What caused these problems?
5. Do others (parents, guardian, and friends) think there were other causes? If so, what
do they say?
6. What other things are currently making it hard to deal with the
problems?
7. What have you already tried in order to deal with the problems?

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8. Why do you think these things didn't work?
9. What have others advised you to do?
10. What do you think would help to solve the problems?
11. How much time and effort do you want to put into solving the
problems?
none at all only a little. just enough very much
If you answered 1st, 2nd, or 3rd option, why don't you want to put
more time and effort into solving the problems?
12. What type of help do you want?
13. What changes are you hoping for?
14. How hopeful are you about solving the problems?

very hopeful hopeful somewhat hopeful
hopeless If you are hopeless, why?
15. What else should we know so that we can help? Are there any other matters
you want to discuss?

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For Interviewer/counselor only: Do not write anything below the line
==============================================================
Name of Interviewer/Counselor: Date:

Note the identified problem:
Is the counselee seeking help? Yes No

If not, what are the circumstances that brought the counselee to the
interview?
Counselor’s Notes:

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For RGC Only
ANNEX C
COUNSELING PLAN
Name of Counselee:
Overall Goals: (case to case

basis) 1.
2.
3.
SESSION # & SPECIFIC GOAL INTERVENTION

DATE
Prepared by:
Signature over printed name of Guidance Counselor

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For RGC Only
ANNEX D
CASE NOTES TEMPLATE
Name of Counselee: Session No.: Date:
Topics discussed during

the session
Relevance of the session

to the counseling plan
Means of achieving the
counseling plan goals
and objectives
Interventions and
techniques used during
the session and their
effectiveness
Counseling observations
Progress or setbacks
Signs, symptoms, and

any increase or decrease
in the severity of
behaviors as they relate
to the main concern
Homework assigned,
results, and compliance
(if any)
The counselee’s current

strengths and
challenges

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ANNEX E
COUNSELEE’S DATA
A. Personal Information
Name:
Grade Level & Section: School:
Birthday: Age: Birth Order:
(Month/Day/Year)
Address:
Contact Number: Email Address:
Gender: ( ) Female Nationality: ( ) Filipino
( ) Male ( ) Foreigner, pls. state country
Religion: Who are you staying with?
( ) Parents ( ) Relatives ( ) Own Family ( ) Alone/Dorm
B. Family Background
Father Mother
Name:
Age:
Educational Attainment:
Occupation:
Contact Number:
Monthly Family Income: (Combined)

( ) below P10, 000.00
( ) P10, 000.00 – 20,000.00
( ) P20, 000.00 –
30,000.00 ( ) above
P30, 000.00
Parents’ Relationship Status

( ) Married and Living
Together ( ) Married but
Separated
( ) Both with other partners ( ) Not Married
( ) Father/Mother with another partner ( ) Deceased, pls.
specify ( ) Both without parents

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Siblings
(Use the back portion if necessary)
Name Age Educational Occupation

Attainment
In case of emergency:
Person to Contact: Age:
Occupation: Contact Number:
Address:
C. Educational Background
Elementary: Year: Honors incurred:

Secondary : Year: Honors incurred:
D. Health
Height: Weight: Blood Type:

Are you suffering from any ailments or handicap?
Are you under any medication?
Did you have any suicidal attempts or thoughts? If yes, when?
Were you a victim of any form of abuse? If yes, when?
Did you get involved with illegal drugs? If yes, when?
Do you have a mentally challenged family member/relative? If

yes, how are you related to him/her?
Have you visited a psychiatrist or psychologist before? (If yes, state the reason)
Counselee’s signature over printed name Date

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ANNEX G:
Recommended Referral Mechanism in different situations
Prior to the referral of cases, schools and the Schools Division Office
shall convene and create a plan of action relative to the referral of cases.
The Schools Division Superintendent shall ensure that referral services
and counseling will be made available for all learners. In consideration of
the different set-ups, number of RGCs, and other concerns, the following
are recommended:
1. For schools that do not have RGCs, but have an RGC in the SDO Level:
a. The school head shall assign a guidance advocate who will facilitate referral of
cases to the SDO level.
b. The guidance advocate shall facilitate the Intake Interview and other necessary
forms, and if deemed necessary, submits the referral letter to the SDO
Guidance Counselor.
c. The SDO Guidance Counselor shall communicate with the referred learner.
d. The SDO Guidance Counselor shall accomplish the counseling plan and
schedule the counseling session.
2. For schools and SDOs with no RGC:

a. The school head shall assign a guidance advocate who will facilitate referral of
cases to the SDO level.
b. The guidance advocate shall facilitate the Intake Interview and other
necessary forms.
c. The guidance advocate prepares the documents necessary to refer the learners
to other counselors in the nearest division or with a partner institution.
3. For schools that do not have an RGC but with a nearby school with RGC:
a. The school head shall assign a guidance advocate who will facilitate the
referral of cases to the nearest school that has an RGC.
b. The guidance advocate shall facilitate the Intake Interview and other
necessary forms.
c. The guidance advocate prepares the documents necessary to refer the learners
to the guidance counselor in the nearest school.
d. The guidance counselor from the nearest school shall accomplish the
counseling plan and schedule the counseling session.

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Referral of Learners (Schools with No RGC)

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ANNEX H
Procedures in conducting an online/tele-counseling

The following should be observed if the learner wants to undergo an
online/tele-counseling. If an RGC is designated in the division level, the
assigned guidance advocate shall facilitate and assist the learner to have
a session scheduled. Regular operation shall take place if a school has an
RGC.
In case a learner really needs counseling, but does not have the needed
resources, the school is highly encouraged to coordinate with the
concerned barangay officials to provide a private space and the needed
resources if possible.
1. The guidance counselor will ask the counselee to accomplish the intake interview form
which shall be sent to the attending guidance counselor prior to the first session. It can
be sent through email or physical submission.
For first timers in counseling, the learner must accomplish the statement
of confidentiality and learner’s data form.
In the event that a learner urgently needs a session with the guidance
counselor, the parent/guardian should help the learner accomplish the
forms, or if not possible, the guidance counselor shall fill out the forms
through an interview with the learner.
2. The guidance counselor will set the schedule of the first session based on their
mutually (guidance counselor and counselee) agreed time and date including the platform
to be used.
3. The guidance counselor shall ensure the platform access of the counselee including
the confidentiality of the session. Both the guidance counselor and counselee should be
in a private space before and during the session.
4. Video and audio recording of the session is not allowed unless there is a mutual
consent between the guidance counselor and the parent of the counselee.
5. Both the guidance counselor and the counselee must ensure that they have enough
technological resources (internet provision) or load; and that the session is free from any
glitches as much as possible to prevent disruption or confusion. The guidance counselor
must also explain to the counselee how the session goes and its limitations using the
identified platform.

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6. Follow-up sessions must be set by both parties as deemed necessary.
7. Should the counseling case merit to be referred to an outside mental health

professional, the referral process should be followed.
8. The guidance counselor shall document the session following the case notes
provisions stated in this guideline.
Note: If the IATF will allow face-to-face interaction, all relevant measures and
guidelines shall be applied to face-to-face counseling.

(043)722-1840 / 722-1796 / 722-1437 / 722-2675 / 722-1662

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Republic of the Philippines

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Prepared: Approved by:

Signature over Printed Name Signature over Printed Name

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

I. PROGRAM TITLE: __________________________________________

VII. SOURCE OF FUND

Signature over printed name

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Home Visitation Form

Student's Name: MENDOZA, JOHN MICHAEL, J. Age: 13

3. Who was/were present?

7. What issues were discussed at the

who is responsible for follow up?

Person Conducting Home Visit: ___________________________

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

HOME VISITATION FORM

Learner’s Reference Number: ___________________

Contact Number: ____________________Class Adviser/Teacher: CHRISTIAN V. MARZO

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Year & Section:

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Pangalan: Petsa ng kapanganakan:

PAG-UUGALI SITWASYON SA PAMILYA

PAG-UUGALI SITWASYON SA PAMILYA

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

PAG-UUGALI SITWASYON SA PAMILYA

SEKSYON GURONG TAGAPAYO

PAG-UUGALI SITWASYON SA PAMILYA

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

PAG-UUGALI SITWASYON SA PAMILYA

PAG-UUGALI SITWASYON SA PAMILYA

SEKSYON GURONG TAGAPAYO

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Date/Time Place Observer Violation Details of the Case Action Taken

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

________Nahuling ⃝nagplano, ⃝nagpasimula, ⃝nakilahok sa alitang ⃝ di-malubhang sakitan, ⃝ walang sakitan

HUWAG PO SANA NINYONG IPAGWALANG BAHALA ANG PAALALANG ITO

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Date of Birth: _________________ Place of Birth: ____________________________________________________

II. EDUCATIONAL BACKGROUND

Age: _________ Occupation: ___________________ Age: _________ Occupation: ____________________

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

IV. SCHOOL MATTERS

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

Counseling services cater to the mental health and well-being of all

There are a few exceptions or limitations to confidentiality in

a. If you are becoming an imminent danger to yourself and/or to others through

Many people are concerned about the confidentiality of meeting with

The following are kept confidential:

Rights and Responsibilities of Client

You have the right to:

• be treated with respect and consideration;

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

By signing this, I have read, understood and agreed to the provisions

Parent’s Signature over printed name Date and Time

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

INTAKE INTERVIEW FORM

2. How serious are these matters for you at this time?

Date of Birth: _ Place of Birth: ____________________________________

Age: _ Occupation: _______ Age: _ Occupation: ________________