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Immaculate Conception Academy Guidance and Counseling Services Individual Inventory Record Form

This document contains an individual inventory record form for a student seeking guidance and counseling services. It collects personal information including name, contact details, family background, educational history, health, interests and hobbies. The form aims to provide counselors insight into the student's circumstances to better assist them.

Uploaded by

Rhieza Perez Umandal
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© © All Rights Reserved
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106 views3 pages

Immaculate Conception Academy Guidance and Counseling Services Individual Inventory Record Form

This document contains an individual inventory record form for a student seeking guidance and counseling services. It collects personal information including name, contact details, family background, educational history, health, interests and hobbies. The form aims to provide counselors insight into the student's circumstances to better assist them.

Uploaded by

Rhieza Perez Umandal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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IMMACULATE CONCEPTION ACADEMY

GUIDANCE AND COUNSELING SERVICES


1X1 PHOTO

INDIVIDUAL INVENTORY RECORD FORM

CAMPUS:________________
STUDENT NUMBER
I.PERSONAL INFORMATION

Name:________________________________________________ Sex:__________Age:_________
(Surname) (Firstname) (M.i)

Grade Level and Section:_____________________Civil Status:___________Date of Birth:__________

Height:_________Weight:_________ Complexion:___________Place of Birth:__________________

City Address:___________________________________________Email Address:________________

Previous General Average:_______________Religion:______________Contact number:_____________

If working, Please indicate the name and address of the employer:______________________________


Person to be contacted in case of emergency:_____________________Relationship: _______________
Address:____________________________Contact details:____________________________________

II.Educational Background

Level School Graduated School Public/p Date of Honors


Address rivate Attend Received/Special
ance Awards
Pre-
elementary

Elementary

High School

Nature of Schooling: [ ] Continuous [ ] Interrupted, Why?___________________________


III. Home Family Background

Name of Father:________________________________ Age:_________ [ ]Living [ ]Deceased


Educational Attainment:_________________________Occupation:____________________
Name of Employer:_____________________________Address________________________

Name of Mother: :________________________________ Age:_________ [ ]Living [ ]Deceased


Educational Attainment:_________________________Occupation:____________________
Name of Employer:_____________________________Address________________________

Name of Gurdian: :________________________________ Age:_________ [ ]Living [ ]Deceased


Educational Attainment:_________________________Occupation:____________________
Name of Employer:_____________________________Address________________________

Parents’ Marital Relatioship: (Please Check)

[ ] Married and Staying together [ ] Single Parent


[ ] Not Married but living together [ ] Married but separated

Number of Children in the family Including yourself:___ Number of Brothers:___ Number of Sisters:__
Number of Brother/s and Sister/s gainfully employed?_______ Ordinal Position(1 st, 2nd child):_______
Is your brother/sister who gainfully employed providing support to your (Please Check)
[ ] Family [ ] Your studies [ ] His/her own family

Who finance your Schooling?


[ ] Parents [ ]Spouse [ ]Relatives
[ ]Brothers and Sisters [ ] Scholarship [ ]Self-Supporting/working student

Do you have quiet place to study: [ ]Yes [ ]No


Do you share your room to anyone: [ ] Yes [ ]No If yes, with whom?___________

Nature of Residence while attending School


[ ] Family Home [ ]Bed spacers/rented apartment
[ ]Relative’s Home [ ] Boarding House/lodging
[ ] Shares apartment with friends/relatives pls specify:_____________IV.HEALTH
A.Physical

Do you have problem with(please Check)


YES NO If yes, please specify
Your vision: [] [] _________________
Your Hearing [] [] _________________
Your speech [] [] _________________
Your General Health [] [] _________________

B. Psychological
Previous Consultations:
CONSULTED YES NO WHEN FOR WHAT
PSYCHOLOGIST
PSYCHIATRIST
COUNSELOR

V. INTERESTS AND HOBBIES


A.Academic
[ ]Math Club [ ]Science club [ ]others, please specify____________________
[ ]Debating club [ ]Quizzer’s club

What is/are your favourite subject/s:________________________________________


What is/are subject/s you least favourite:___________________________________

B. Extra-Curricular
What are your hobbies? Write them in the order of your preferences.
1.________________ 3___________________
2________________ 4___________________

Which of the Following organization have you participated in and which interest you most? (Please
specify)
[ ]Athletics [ ]Religious [ ]Glee Club [ ]others, please specify_________________
[ ]Drama [ ]Chess Club [ ]Scouting

Occupational position in the organization: [ ]Officer [ ]Member [ ] others, please


specify____________

VI.SIGNIFICANT NOTES: (FOR GUIDANCE COUNSELOR ONLY)


DATE INCIDENT REMARKS

Student’s Signature
Note:All of your information will be kept strictly confidential

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