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COUNSELLING REQUEST FORM
(To be filled up by the Programme Coordinator, Lecturers, Student Affairs)
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Email
*
Your email
1. Student's Detail
Name
*
Your answer
Telephone Number:
*
Your answer
Age:
*
Choose
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
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61
62
63
64
65
66
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68
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70
Gender
*
Female
Male
Intake
*
Your answer
Programmes
*
Choose
Diploma in Physiotherapy
Diploma in Medical Imaging
Diploma in Medical Laboratory Technology
Diploma in Environmental Health
Diploma in Pharmacy
Diploma in Business Administration
Diploma in Accounting
Diploma in Entrepreneurship
Foundation in Science
Certificate in Business Studies
Certificate in Health Science
Diploma in Teaching English as a Second Language
Option 13
Reason(s) of Referral:
*
(Please check all that apply.)
Dramatic change in behavior
Worries
Daydream/fantasizes
Grief
Fears
Sadness
Always tired
Motivation
Inattentive
Withdrawn
Perfectionist
Aggression/Anger
Swearing
Fighting
Lying
Bullying
Disrespectful
Hurts self
Impulsive
Over Active
Easily distracted
Chews (paper/clothes/hair)
Makes Odd Sounds
Stealing
Destruction of Property
Sexual Acting Out
Peer Relationships
Social Skills
Personal Hygiene
Family Concerns
Academics
Absences
Tardy
Completion of Assignments/Homework
Drop out risk
Other:
Required
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