[Counseling Service Referral Form]


hopefully this:

  1. is easier than printing, signing, scanning and sending
  2. is safer than walking around asking people to sign during pandemic
  3. is less worrisome than sending around electronic photos of signature
  4. fills up the gap of google form for not having signatures
  5. enables the creation of online forms faster than development of systems for each form


Counseling Service Referral Form

user: Login with AOLIS employee account for college enrollment | Login with AOLIS Student Account | Login with @aup.edu.ph AUP Email account | | time: Wed May 22 04:15:52 PST 2024 , forminstanceid: 0 Last signed: . Last edited: . | Signatures/Approvals: 0/0

Name of Client to be Referred

Program / Year Level

Referred by

Today's Date

Reason/s for the Referral - Problems / Concerns Related:

  • Frequent Absenteeism: The students incurred 3 to 4 absences in certain courses.

  • Course


  • Frequent Tardiness. The student is observed to be habitually late.

  • Sanction from Behavioral Management Office / SSO: These are sanctions or disciplinary actions issued by the Behavioral Management Office or Student Services Office.

  • Document Attachment

  • Poor cognition. The student shows difficulty understanding even simple instructions; is inattentive, or has bizarre thoughts

  • Displaying Abrasive or Aggressive Behavior: The student exhibits conduct that is harsh, forceful, or confrontational, often characterized by a lack of tact, sensitivity, or consideration for others. This behavior may involve using harsh language, being overly critical, or expressing hostility towards others.

  • Noticeable Changes in Personal Hygiene: The student declined practicing hygiene such as bathing, tooth brushing, hair care, or overall cleanliness.

  • Loss of Appetite and Sleep Difficulties: The student expressed or appeared as if having loss of appetite and difficulty of sleep.

  • Suicidal Attempts: A student exhibits behavior indicating self-harm or reveals plans to end their life.

  • Expressed feeling depressed or anxious: Student has expressed having problems with his or her mental health

  • Misconduct: The student is uncooperative, disrespectful, and defiant.

  • Others (Specify): Include any additional observable behaviors not covered by the above categories, specifying the nature of these behaviors.

  • Counselor’s feedback/Action Taken

    Send to guidance@aup.edu.ph

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