GUIDANCE & COUNSELING OFFICE
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STUDENT INTAKE
CONFIDENTIAL
CONFIDENTIAL
DATA PRIVACY STATEMENT
The Guidance and Counseling Office (GCO) of Visayas State University acknowledges its responsibilities under
Republic Act No. 10173, also known as the Data Privacy Act of 2012, concerning the collection, recording, organization,
updating, use, consolidation and destruction of data from registered participants. The personal data collected through
this Form will be necessary to achieve the educational, institutional, and other legitimate interests of VSU, including for
guidance and counseling purposes and will be accessible only to authorized GCO personnel, ensuring compliance with
data privacy and protection standards.
I have read and agree with the VSU Data Privacy Policy and Guidelines, by affixing my signature below:
Signature over Printed Name/ Date
INSTRUCTIONS Fill-out legibly in CAPITAL letters. Use blue ink. Put an X mark in appropriate box when indicating a choice.
DEMOGRAPHIC INFORMATION
LEGAL NAME:
Last Name: First Name: M.I.:
HOME ADDRESS: DATE OF BIRTH:
mm / dd / yyyy
CONTACT NO.:
Indigenous People Solo Parent Foreign Student (Nationality: ________________________)
MINORITY GROUP:
(IF APPLICABLE) Person With Disability (Disability: ________________________)
Lesbian Gay Bisexual Transgender Queer Straight
SEXUAL ORIENTATION:
Would rather not to say Other: ____________________
Single Married Annulled Separated Widowed Cohabitating
RELATIONSHIP SATUS:
In a romantic relationship Other:____________________
CONTACT PERSON DURING EMERGENCIES:
CONTACT NUMBER: E-MAIL ADDRESS:
Can we call / leave a message? YES NO Can we email? YES NO
ALTERNATE NUMBER: RELATIONSHIP WITH:
Can we call / leave a message? YES NO
ACADEMIC INFORMATION
Degree Program: Major:
ACADEMIC LEVEL: Freshman Transferee
GUIDANCE & COUNSELING OFFICE
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FAMILY INFORMATION
FATHER: MOTHER: (MAIDEN NAME)
Living Deceased Living Deceased
NO. OF SIBLINGS: BIRTH ORDER: First Middle Last Other: ____________
BIRTH STATUS: Biological child Adopted Other: _________ __ _
RELATIONSHIP: Please describe your relationship with your family using the scale (1-low; 5-high). Put X on the box.
Adapted: Hendrick, S. S. (1988). A generic measure of relationship satisfaction. Journal of Marriage and the Family, 50, 93–
98.
1 (Low) 2 3 4 5 (High)
How well does your family members meet your needs? 1 2 3 4 5
In general, how satisfied are you with your family relationship? 1 2 3 4 5
How good is your family relationship compared to most? 1 2 3 4 5
How often do you wish you hadn’t gotten into this family? 1 2 3 4 5
To what extent has your family relationship met your original expectations? 1 2 3 4 5
How much do you love your family? 1 2 3 4 5
How many problems are there in your family relationship? 1 2 3 4 5
MENTAL HEALTH HISTORY
Have you visited a psychiatrist before? YES ON-GOING (Doctor: ___________________________) NO
Have you been diagnosed with mental health condition? YES (Diagnosis: _________________________) NO
Have you taken medications for mental YES ON-GOING (Medicines: ________________________) NO
health treatment before?
Have you had counseling or psychotherapy YES ON-GOING (Provider: _________________________) NO
sessions before?
Have you experienced hurting yourself but YES (Specify: ________________________) NO
did not want to die (e.g. cutting)?
Have you thought of committing suicide? YES NO
Have you attempted to commit suicide? YES NO
Do you have concerns on substance use? YES NO
WELL-BEING
Please encircle the number that best describe your experience in the past two weeks.
The Warwick–Edinburgh Mental Well-being Scale (WEMWBS) None of the Rarely Some of the Often All of the
time time time
I’ve been feeling optimistic about the future. 1 2 3 4 5
I’ve been feeling useful. 1 2 3 4 5
I’ve been feeling relaxed. 1 2 3 4 5
I’ve been feeling interested in other people. 1 2 3 4 5
I’ve had energy to spare. 1 2 3 4 5
I’ve been dealing with problems well. 1 2 3 4 5
I’ve been thinking clearly. 1 2 3 4 5
I’ve been feeling good about myself. 1 2 3 4 5
I’ve been feeling close to other people. 1 2 3 4 5
I’ve been feeling confident. 1 2 3 4 5
I’ve been able to make up my own mind about things. 1 2 3 4 5
I’ve been feeling loved. 1 2 3 4 5
I’ve been interested in new things. 1 2 3 4 5
I’ve been feeling cheerful. 1 2 3 4 5
Source: NHS Health Scotland, University of Warwick and University of Edinburgh (2006).
NEEDS, ISSUES, AND CHALLENGES
What issues or challenges you need help with while you are here in the University?
