Capitol University

GUIDANCE CENTER

Corrales/Osmeña St., Cagayan de Oro City

 

CU-QMS-GO-002

REFERRAL SLIP

 

Name of Referral: _______________________________      Date Referred: __________________

Course & Year: _________________________________                  Position Applied: __________________

(for students/ETEEAP)                                                       (for Employment Referral only)

(     )  FOR COUNSELING

 

(    )  FOR PSYCHOLOGICAL TESTING

Examination Date: __________________

 

(   )  Irregular Attendance                      (   ) Illness

Psychological Assessment

(   )  Prolonged absence                                    (   )Physical handling (   ) Employment
(   )  Lack of interest in school work        (   ) Poor personal habit (   ) ETEEAP
(   )  Lack of School materials                 (  ) Behavior problem (   ) Special Case
(   )  No Breakfast / lunch(   ) other (pls. Specify) _______________________________

 

To be filled up by the Psychometrician:For Interview on: ___________________

Referred by: _____________________________                  College/Office:__________________________

Name & Signature

Designation: _____________________________

 

 

Issue: April 2006                                                                                                                                                                     Rev. Code 3

 

Capitol University

GUIDANCE CENTER

Corrales/Osmeña St., Cagayan de Oro City

 

CU-QMS-GO-002

REFERRAL SLIP

 

Name of Referral: _______________________________      Date Referred: __________________

Course & Year: _________________________________                  Position Applied: __________________

(for students/ETEEAP)                                                       (for Employment Referral only)

(     )  FOR COUNSELING

 

(    )  FOR PSYCHOLOGICAL TESTING

Examination Date: __________________

 

(   )  Irregular Attendance                      (   ) Illness

Psychological Assessment

(   )  Prolonged absence                                    (   )Physical handling (   ) Employment
(   )  Lack of interest in school work        (   ) Poor personal habit (   ) ETEEAP
(   )  Lack of School materials                 (  ) Behavior problem (   ) Special Case
(   )  No Breakfast / lunch

(   ) other (pls. Specify) _______________________________

To be filled up by the Psychometrician:

For Interview on: ___________________

Referred by: _____________________________                  College/Office:__________________________

Name & Signature

Designation: _____________________________

 

 

Issue: April 2006                                                                                                                                                                     Rev. Code 3

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