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REKOD SELIAAN B3

REKOD SELIAAN KAUNSELOR


MAKLUMAT DIRI

Nama : __________________________________________

Tingkatan : __________________________________________

No.KP : __________________________________________

Alamat : __________________________________________

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No.Telefon : ___________________________________________

PENYALAHANGUNAAN BAHAN

1. Tarikh / Bulan / Tahun mula mencuba rokok :


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2. Bilangan rokok yang dihisap dalam sehari:


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3. Tarikh akhir merokok :


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4. Jenis dadah / inhalan yang dicuba :

Heroin Morfin Syabu


Ganja
Gam Arak Ubat Batuk Lain-lain
REKOD SELIAAN B3
Jika Lain-lain sila nyatakan :
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Bil.kali
mencuba Tarikh mula Tarikh akhir
Dadah/Inhalan
hingga mencuba mencuba
sekarang
Heroin kali
Morfin kali
Syabu kali
Ganja kali
Gam kali
Arak kali
Ubat Batuk kali
Lain-lain kali

5. Dengan siapa anda mencuba :


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6. Di mana tempat mencuba :
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7. Dari mana di dapati bekalan :
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8. Mengapa anda mencuba dadah :
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9. Pelajar lain yang anda tahu pernah mencuba dadah :
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10. Setakat ini berapa jumlah wang yang digunakan membeli dadah /
inhalan ?
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11. Pernah anda disiasat oleh polis ?
Ya tidak
REKOD SELIAAN B3
( jika ya nyatakan sebabnya )
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12. Keputusan ujian air kencing


12.1 Tarikh : _________________________________________
12.2 Keputusan : positif negatif

ULASAN KAUNSELOR

1. Sesi Pertama Kaunseling Selepas Ujian Urin :

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2. Sesi Selepas 3 Bulan Pertama Menghadiri Sesi Kaunseling / PIP :

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REKOD SELIAAN B3
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3. Sesi Selepas 6 Bulan Pertama Menghadiri Sesi Kaunseling / PIP :

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4. Sesi Selepas 1 Tahun Pertama Menghadiri Sesi Kaunseling / PIP :

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REKOD SELIAAN B3
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KOMITMEN IBUBAPA

1. Kekerapan mengadaakan pertemuan dengan pihak sekolah


B
ISU Tempat Tarikh Catatan
il

2. Penyertaan dalam aktiviti yang dianjurkan oleh pihak sekolah

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REKOD SELIAAN B3
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3. Pandangan secara umum terhadap ibubapa / penjaga klien

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MAKLUMAT PEMANTAUAN

BI TARIK MAS JENIS TINDAKAN/CAT


TEMPAT
L H A KAUNSELING ATAN
REKOD SELIAAN B3

TANDATANGAN KAUNSELOR
PENGESAHAN
PENGETUA