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Referral Form-Annex F

This document provides guidelines for referring learners to counseling. It outlines behaviors that may indicate a need for counseling like poor performance, lack of interest, isolation, or signs of depression. It instructs teachers to inform the learner and parents about observed behaviors and suggest counseling. The learner's consent is preferred but not required if their behavior endangers themselves or others. A referral form is included to track the status of the case like whether counseling sessions are ongoing or completed.

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Christine Joy Maranan
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79 views1 page

Referral Form-Annex F

This document provides guidelines for referring learners to counseling. It outlines behaviors that may indicate a need for counseling like poor performance, lack of interest, isolation, or signs of depression. It instructs teachers to inform the learner and parents about observed behaviors and suggest counseling. The learner's consent is preferred but not required if their behavior endangers themselves or others. A referral form is included to track the status of the case like whether counseling sessions are ongoing or completed.

Uploaded by

Christine Joy Maranan
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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Guidelines in Referring

Learners to GCO COUNSELING REFERRAL FORM


A.
Name of Student:
B. A. CHECK THE LEARNER’S
BEHAVIORS THAT INDICATE THE
Grade & Level :
NEED FOR HELP Gender:
A student who may need Date of Referral:
counseling would likely manifest Reasons for Referral:
the following behaviors:
 Talks aloud and distracts others in
class Initial Actions Taken:
 Is often late or absent
 Performs very poorly in both oral
and written exams Did the student agree to be referred to GCO: ____YES ____NO
 Shows lack of interest and
Parent/Guardian’s Name:
motivation in his or her studies
 Isolates himself or herself from the Parent/Guardian’s Contact Number:
group Referred by:
 Seems to be perpetually tired, Designation:
ANNEX F
anxious, depressed, irritable, Contact Number:
angry, etc.
 Fails to submit work on time
 Manifests deterioration in grooming
or hygiene COUNSELING REFERRAL
 Shows signs of dramatic weight ACKNOWLEDGEMENT FORM
loss or gain, etc.
 Talks about SUICIDE To: (Referring Person / Unit)
Designation/Department:
C. B. TALK TO THE LEARNER ABOUT
THE NEED TO SEEK This is to confirm that
PROFESSIONAL HELP ___________________________whom you referred to us
If you observe any of the above on_________________________had started his/her session on
behaviors, here's how to proceed: _____________________ and is being attended
 Inform the learner and/or the by________________________________________________.
parent regarding the behavioral Kindly refer to the checklist below on the status of the case at hand.
patterns that you have observed in
□ Closed at Intake Interview
a professional and confidential
manner. □ For Counseling
 Listen to the person's situation. □ Counseling Sessions are on-going
 Suggest to the learner (and □ Parent/Guardian Conference Conducted
parents) that they may consider □ Sessions Completed / Case Terminated
availing of the counseling services □ Student did not show up
provided by the GCO for free. □ Under Monitoring
 Respect the person being referred. □ Number of follow-ups made by the Counselor: ______
A learner has the option to refuse a □ Referred to ___________________________________________
referral.
 However, if his or her behavior Thank you.
endangers one's well-being and Always for the welfare of students,
those of others, it is our utmost
______________________________
responsibility to provide such help
to the learner without necessarily
Attending Guidance Counselor
getting his or her consent.
Date:

ANNEX G:

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