WAFIF Counselling Department
Personal Data Form (Child/Adolescent)
Child's Full Name
*
First Name
Last Name
Age
Email
example@example.com
Address
Street Address
Street Address Line 2
City
Parish/State
Country /Zip Code
Phone Number
Format: (000) 000-0000.
Parent/Guardian's Full Name
First Name
Last Name
Parent/Guardian's Phone Number
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Name of School
Current Grade
Positions Held at School
Clubs/Societies
How do you feel about your school? What are your likes and dislikes?
Who do you live with? List all the members of your household. eg, mother, cousin, aunt etc. Do not give specific names.
What are the things in your life that you worry about the most or that bother you the most?
*
Are you a committed Christian?
Yes
No
Not Sure
Type option 4
Church you attend
*
Involvement at Church
Medical Problems, Chronic Illnesses or surgeries
Last Medical Evaluation
Doctor's Name , Address and Telephone Number
Tick the words that best describe you.
Outgoing
Ambitious
hardworking
Calm
Aggressive
Sad
Fearful
Anxious
Shy
Hopeless
Determined
Brilliant
Disciplined
Lonely
Reserved
Kind
Hurt/Wounded
Other
What is your main reason(s) for seeking counselling? Describe the problems you are having.
If you could have three (3) wishes granted, what would those be?
Hobbies:
Talents:
What do you do for fun?
Career Goal
Life Ambition
Describe how you see yourself ten years from today.
Date of Submission
-
Month
-
Day
Year
Date
Parental Consent: (To be signed by Parent/Guardian) I……………………………………………….. hereby grant permission for my child/ward to receive individual counselling at the WAFIF Counselling Department.
Please verify that you are human
*
SUBMIT
Should be Empty: