Republic of the Philippines

CAMIGUIN POLYTECHNIC STATE COLLEGE

Balbagon, 9100 Mambajao ,Camiguin
Tel. No. (088)3870495 │ camiguinpolytechnic@yahoo.com
Website: www.cpsc.edu.ph

Guidance and Counseling Office (GCO)

CASE NOTE
______Semester; AY: ____________
Client’s Name Course & Year Client ID Date

Format of Session: ______Face to face ______Phone ____Others_______________

No. of Session: _______ Time in: ___________ Time out: ___________
Nature of Session: _____Interview _____Academic _____Entry/initial/Befriending
_____Emotional _____Spiritual _____Exit/Placement/Career
_____Personal Others, specify____________________________________
Intervention: __________________________________________________________________________________
Status at end of the session: _____________________________________________________________________
Over-all progress since last session: (Check Response)
___ met goal ___some improvement ___no improvement

Achieved today:
___goals & objectives identified ____barriers identified ____objectives & action shape developed

Other service/s provided: ________________________________________________________________________

Referrals: (Check all that apply)

_____ Need specialist _____ Client to contact referral source
_____ Referral made during session _____ Referral forms were completed

Follow-up on previous referrals: (if any) ____ Completed ____ Did not complete

Case Notes
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Counselor’s Signature: ______________________________ Date: _________

Document Title: COUNSELING CASE NOTE

Document Code: CPSC-QMS-F006 Rev. No.: 00 Effective Date: October 1, 2019 Page 1 of 1