RTU-SS-GCC-F-005

Rizal Technological University CONTROL #_____-_____-______

Cities of Mandaluyong & Pasig
534-82-67
GUIDANCE AND COUNSELING CENTER RECENT
2X2 PHOTO
WITH
Individual Inventory Form BLUE
BACKGROUND
COURSE:________________________________

Please fill up the following information below. Rest assured that all information will be treated with confidentiality.
Thank you for your cooperation.

PERSONAL INFORMATION
Name:___________________________________________________________________Nickname:_______________________
Present Address: ________________________________________________________________________________________
Provincial Address: ________________________________________________________________________________________
Date of Birth: _____________ Place of Birth: _______________ Birth Order: _______________ Number of Siblings: _________
Age: _________ Gender: ____________ Civil Status: ________________ Religion: _____________ Nationality: ____________
Home Phone No. _________________________ Mobile No.: ___________________ Email Add: _________________________
Weight: _________________________________ Height: ______________________ Blood Type: ________________________
Hobbies/Interest: __________________________________________________________________________________________
Talents: _________________________________________________________________________________________________
In case of emergency, please notify: ____________________________________________ Relationship: ___________________
Address: ________________________________________________________________ Contact No. ______________________

FAMILY BACKGROUND
Father Mother
Name
Age
Highest Educational Attainment
Occupation
Average Income per Month
Contact Number / s

Status of Parents
Married and living together Legally separated
Living in (not married) Mother (Widow)
Separated Father (Widower)
Father is with another family
Mother is with another family

ACADEMIC INFORMATION

Level Name of School Year Graduated Awards Received

Elementary
Junior High School
Senior High School
Track:__________________
Strand: _________________

Subjects interested to: ______________________________________________________________________________________

Organization Membership: __________________________________________________________________________________
How is your studies financed? _______________________________________________________________________________
Is your present course / program your personal choice? Yes No

RIZAL TECHNOLOGICAL UNIVERSITY REV=0 EFFECTIVITY: SEPTEMBER 1, 2015

RTU-SS-GCC-F-005

If no,

A. Who influenced you? _____________________________________________________________________________

B. How do you feel about the course not being your first choice? _____________________________________________
_________________________________________________________________________________________________
C. What is your personal choice? ______________________________________________________________________

Why did you choose to enroll in RTU?

Quality Education
Free Tuition Fee
Competitive Faculty Members
Good facilities
Proximity and accessibility
Good reputation
Recommended by friends, relatives, etc.
Performance in the licensure examination
Others, please specify: _________________________________________________________________________

What other school do you consider?

JRU STI ABE ARELLANO

PUP AMA EARIST PNU
UMAK Others, please specify__________________________

BEHAVIOR INFORMATION

Check if you ever experience the

When did it happen? Does it still bothering you?
following concerns:
Bullying Yes No
Suicidal thoughts Yes No
Suicidal attempts Yes No
Panic attacks Yes No
Anxiety Yes No
Depression Yes No
Self / Anger Management Issues Yes No
Recurring negative thoughts Yes No
Low self-esteem Yes No
Poor study habits Yes No
Poor in decision making Yes No
Impulsivity Yes No
Poor sleeping habits Yes No
Loss of appetite Yes No
Over-eating Yes No
Poor hygiene Yes No
Withdrawal / Isolation Yes No
Family problem Yes No
Other relationship problems Yes No
Alcohol addiction Yes No
Gambling addiction Yes No
Drug addiction Yes No
Computer addiction Yes No
Sexual harassment Yes No
Sexual abuse Yes No
Physical abuse Yes No
Verbal abuse Yes No
Pre-marital sex Yes No
Teenage pregnancy Yes No
Abortion Yes No
Extra marital affairs Yes No

RIZAL TECHNOLOGICAL UNIVERSITY REV=0 EFFECTIVITY: SEPTEMBER 1, 2015

 RTU-SS-GCC-F-005

PREVIOUS PSYCHOLOGICAL CONSULTATIONS

Have you consulted a PSYCHIATRIST before? Yes No

If YES, for what reason? ___________________________________________ When? _________________________________
Have you consulted a PSYCHOLOGIST before? Yes No
If YES, for what reason? ___________________________________________ When? _________________________________
Have you consulted a COUNSELOR before? Yes No
If YES, for what reason? ___________________________________________ When? _________________________________

PERSONAL DESCRIPTION (Tell something about yourself)

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

I hereby affirm that all information supplied herein is complete and is accurate and may be verified against original
documents.

___________________________ ___________________________
Student’s signature Date Accomplished

RIZAL TECHNOLOGICAL UNIVERSITY REV=0 EFFECTIVITY:

SEPTEMBER 1, 2015