ACADEMIC COUNSELING FORM

Student Name: ____________________________________ Student ID # _____________

For SY/Sem: ______________________________________ Date: ____________________

This is to acknowledge that I:

_____ incurred ______ absences/tardiness

_____ am not motivated in class
_____ failed _______________________________, a major / minor subject in my course for the
midterm period.

With my status, I am expected to:

 Review and understand the policies and procedures related to the Retention Policy for the
______ (course) _______ under the School of Nursing and Allied Medical Sciences and the Holy
Angel University in the Student Manual.
 I must meet periodically with my professor to discuss my academic standing.
 I will not incur absences and tardiness.
 My professor and I discussed the following related to my academic success:

_____ Study habits _____ Time management

_____ Class attendance _____ Changed course more than one time
_____ Work schedule _____ Undecided about the course
_____ Family concerns _____ Other: _____________________________
 To support my academic success, I will make use of suggested campus resources including:

_____ Tutoring _____ Academic/Transfer Advising

_____ Career Counselling _____ Study Assistance
_____ Personal Counselling _____ Other: _____________________________
 My professor and I met and discussed with me the college’s interest in my success and the many
resources available to help me. I understand that I can meet with him/her at any time during
consultation hours or with the other appropriate college staff who can assist me in achieving my
goals.

Conforme:

Student name and signature: _____________________________________________________________

Parent/Guardian name and signature: ______________________________________________________

Mobile and Land phone number: __________________________________________________________

(Attach ID with signature of the signed parent)

Noted:

Instructor: ____________________________________________________________________

Guidance Counselor: ____________________________________________________________

Program Chairperson/Coordinator: ________________________________________________

College Dean: __________________________________________________________________