PEMERINTAH KOTA PALEMBANG

DINAS PENDIDIKAN PEMUDA DAN OLAHRAGA

SMA NEGERI 5 PALEMBANG

Jalan Gotong Royong Sungai Buah, Provinsi Sumatera Selatan
Telepon (0711) 713259 Fax (0711) 713259 Palembang 30116
Website :http://www.sman5palembang.sch.id

CATATAN HOME VISIT

KELENGKAPAN DATA BIMBINGAN YANG SEDANG DI KUMPULKAN , A.N :
Nama Konseli
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Kelas / Tahun Ajaran
: ..........................................................................................................
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Jenis masalah
: ..........................................................................................................
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Nama orang Tua
: ..........................................................................................................
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Alamat
Rumah
: ..........................................................................................................
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KRONOLOGI PELAKSANAAN HOME VISIT :
URAIAN SINGKAT KEBERANGKATAN
1. Hari / tanggal / jam berangkat
:.......................................................................................................
2. Data yang ingin diperoleh dari kegiatan HOME
VISIT :............................................................................
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URAIAN SINGKAT HASIL DARI HOME VISIT :

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TINDAK LANJUT :
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Palembang,
Konselor

(.......................................................
......)
NIP.

PEMERINTAH KOTA PALEMBANG

DINAS PENDIDIKAN PEMUDA DAN OLAHRAGA

SMA NEGERI 5 PALEMBANG

Jalan Gotong Royong Sungai Buah, Provinsi Sumatera Selatan
Telepon (0711) 713259 Fax (0711) 713259 Palembang 30116
Website :http://www.sman5palembang.sch.id

CATATAN KONSELING

KELENGKAPAN DATA BIMBINGAN YANG SEDANG DIKUMPULKAN , A.N :

Nama Konseli
: ...................................................................................................................
...
Kelas / T.A
: ...................................................................................................................
...
Pertemuan : .........................................................................................................
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Hari/tanggal/jam : ...............................................................................................
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1. ANALISA DATA
KELUHAN AWAL :
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DATA YANG RELEVAN DENGAN KELUHAN KONSELI :
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2. DIAGNOSA

IDENTIFIKASI MASALAH
Kesehatan fisik
Kesehatan mental
:
Hubungan keluarga
:
Keadaan sosial ekonomi
Hubungan sosial
di rumah
Hubungan sosial di sekolah
Pemanfaatan waktu senggang

:
:
:
:
:

3. THREATMENT
Pendekatan konseling yang relevan
:
Client centered
Directive
Psikoanalisa
Alternatif penyelesaian masalah / pemenuhan terhadap kekurangan
kekurangan :
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4. TINDAK LANJUT
TAHAP I
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TAHAP II
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TAHAP III
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Palembang,
Konselor
(.......................................................
..............)
NIP.