OFFICE OF STUDENT AFFAIRS

Counseling and Testing Section

UNIVERSITY OF THE PHILIPPINES MINDANAO

STUDENT ACADEMIC AND PSYCHOSOCIAL FORM

AY ________________________

TO BE FILLED UP BY THE STUDENT

Name: Student No.: Course/Year:

Address Age: Contact Nos. and E-mail:

Sex:

Gender: [ ] Masculine Birthday and Place of Birth: Marital Status:

[ ] Feminine

Cultural minority [ ] No Religion: Dialect:

[ ] Yes, Specify
Student Type: [ ] New Student Who Finances Your Study: [ ] Parents
[ ] Continuing student [ ] Scholarship, specify:
[ ] Shiftee from another course
[ ] Transferee from another UP unit
[ ] Transferee from another school [ ] Others, specify:
[ ] Returning from LOA/AWOL
Living Arrangement while in UP Manila: Annual Family Income:
[ ] |Staying in own house - ( ) with family ( ) alone [ ] above 1M
[ ] Renting an apartment - ( ) with family ( ) alone ( ) with friends or schoolmates [ ] 700,000 – 999,999
[ ] Renting a condominium - ( ) with family ( ) alone ( ) with friends or schoolmates [ ] 500,000 – 699,999
[ ] Staying in a dormitory//boarding house [ ] 250,000 – 499,999
[ ] Staying in relative's/friend's house [ ] 100,000 – 249,999
[ ] Bedspacer [ ] below 100,000
[ ] Others, specify:
Family Status: Parent/s' Work Status: Student's Work Experience:
Parents: [ ] both living Father [ ] No [ ] Never worked
[ ] both deceased [ ] Yes, abroad? ( ) Yes ( ) No [ ] Worked but stopped already
[ ] deceased ( ) father ( ) mother [ ] Currently working fulltime
Mother [ ] No [ ] Currently working part-time
Siblings: No. ______ [ ] Yes, abroad? ( ) Yes ( ) No

Membership in Organizations: Hobbies:

In school:

In the community or elsewhere:

TO BE FILLED UP BY THE ADVISER OR ATTENDING GSS

 Academic/ Career Plan Plan:

How to Achieve the plan:

Career Concerns

Degree of Satisfaction on Campus Experience Notes:

Rating*:
Problems in and outside school Notes:

Rating*:
Overall satisfaction in life Notes:

Rating*:
Additional Notes:

* Rate the student experience from 1-10, 10 being the highest