Republic of the Philippines

Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN

ANNEX E.
COUNSELEE’S DATA
A. Personal Information

Name: _____________________________________________________
Grade Level & Section: ____________________ School: ________________
Birthday: ______________ (m/d/y) Age: _____ Birth Order: _____________
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 Php 10, 000.00

( ) Php 10,000.00 – 20,000.00
( ) Php 20, 000.00 – 30, 000.00
( ) above Php 30, 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
_________________

Address: Magsaysay, Dinalupihan, Bataan

Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@gmail.com
 Republic of the Philippines
Department of Education
REGION III – CENTRAL LUZON
SCHOOLS DIVISION OFFICE OF BATAAN
MAGSAYSAY NATIONAL HIGH SCHOOL
MAGSAYSAY, DINALUPIHAN, BATAAN

( ) Both without parents

Siblings
(Use the back portion if necessary)

Name Age Educational Occupation

Attainment

In case of emergency:
Person to contact: ________________________________________________
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 of 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

Address: Magsaysay, Dinalupihan, Bataan

Telephone No: (047) 613-21-36
Email Address: magsaysaynhs.306604@gmail.com