B3

REKOD SELIAAN KAUNSELING

GAMBAR
A. MAKLUMAT DIRI KLIEN

Nama : __________________________________________

Tingkatan : __________________________________________

No. Kad : __________________________________________

Pengenalan

Alamat : __________________________________________

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No. Telefon : ___________________________________________

B. PENYALAHANGUNAAN BAHAN TERLARANG

1. Intervensi kaunseling melalui:

a. Dirujuk positif ujian urin Jenis bahan: ....................................

b. Dirujuk kes disiplin Jenis bahan: ....................................

c. Dirujuk kes tangkapan Jenis bahan: ....................................

d. Sukarela/Pengakuan klien Jenis bahan: ....................................

2. Keputusan Ujian Saringan Urin (jika ada)

2.1 Tarikh : ...................................................

2.2 Keputusan : positif negatif

2.3 Jenis saringan : kertas jalur klinikal

3. Jenis bahan terlarang yang dicuba:

Bil. mencuba hingga Tarikh mula Tarikh akhir
Bil Bahan
sekarang mencuba mencuba
1 Rokok kali
2 Heroin kali
3 Morfin kali
4 Syabu kali
5 Ganja kali
6 Gam kali
7 Arak kali
8 Ubat Batuk kali
9 Lain-lain kali

4. Dengan siapa anda mencuba : _________________________________________

5. Di mana tempat mencuba : _________________________________________
6. Dari mana didapati bekalan : _________________________________________
7. Mengapa anda mencuba dadah : _________________________________________
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8. Murid lain yang anda tahu pernah mencuba dadah :

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9. Setakat ini berapa jumlah wang yang digunakan membeli dadah/inhalan ?
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10. Pernah anda disiasat oleh polis ?
Ya Tidak
( jika ya nyatakan sebabnya ) _______________________________________________
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C. ULASAN/RUMUSAN GURU BIMBINGAN KAUNSELING

1. Sesi Pertama Kaunseling Selepas Ujian Saringan Urin :

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2. Sesi Kedua Kaunseling Selepas Ujian Saringan Urin :

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3. Sesi Ketiga Kaunseling Selepas Ujian Saringan Urin :

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4. Sesi Keempat Kaunseling Selepas Ujian Saringan Urin :

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5. Sesi Kelima Kaunseling Selepas Ujian Saringan Urin :
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CATATAN:

1. Setiap sesi kaunseling hendaklah disokong dengan Borang Rekod kaunseling Individu BK08.

2. Ulasan pada ruangan ini hanyalah secara umum manakala ulasan penuh dicatatkan pada
BK08.

D. KOMITMEN IBUBAPA
1. Kekerapan ibubapa mengadakan pertemuan dengan pihak sekolah
Bil Isu/Perkara dibincangkan Tempat Tarikh Catatan
2. Penyertaan klien dalam aktiviti yang dianjurkan oleh pihak sekolah

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3. Pandangan secara umum Guru Bimbingan kaunseling terhadap ibu bapa/penjaga klien

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 E. MAKLUMAT PEMANTAUAN

BIL TARIKH MASA TEMPAT JENIS KAUNSELING TINDAKAN/CATATAN

1
2
3
4
5
6
7
8
9
10

Nota Penting:
1. Guru Bimbingan Kaunseling perlu melaksanakaan intervensi PPDa(kaunseling Individu) kepada
murid yang disahkan positif Ujian Saringan Urin oleh AADK sekurang-kurangnya sekali sebulan
dalam tempoh 3 bulan pertama.
2. Sesi kaunseling bersama murid hendaklah disokong dengan FAIL SULIT agar segala aktiviti
intervensi dapat direkodkan dengan tersusun.
3. Ujian Saringan Urin perlu dibuat ke atas murid berkenaan selepas selesai menjalani sesi
kaunseling bersama Guru Bimbingan Kaunseling. Jika murid masih positif, perbincangan
sekolah bersama ibubapa dan AADK atau pihak lain yang berkenaan hendaklah dijalankan bagi
membincangkan tindakan seterusnya yang perlu diambil agar murid terus dapat dibantu.

TANDATANGAN KAUNSELOR PENGESAHAN

PENGETUA

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RUMUSAN KESELURUHAN SESI KAUNSELING UJIAN SARINGAN URIN

Telah Menjalani Ujian Saringan Urin 2 Belum

Tarikh : ................................................

PERKEMBANGAN KLIEN
Sahsiah:

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Kehadiran:

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Akademik:

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Sesi ditamatkan

Tarikh : .......................................

Catatan : ..................................................................................................................

Sesi diteruskan

TANDATANGAN KAUNSELOR PENGESAHAN PENGETUA

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