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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 : _____________________________

2. Bilangan rokok yang dihisap dalam sehari : _____________________________

3. Tarikh akhir merokok : _____________________________

4. Jenis dadah / inhalan yang dicuba :

Heroin Morfin Syabu Ganja


Gam Arak Ubat Batuk Lain-lain

Jika Lain-lain sila nyatakan : __________________________________


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

5. Dengan siapa anda mencuba : _________________________________________


6. Di mana tempat mencuba : _________________________________________
7. Dari mana di dapati bekalan : _________________________________________
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
( jika ya nyatakan sebabnya ) _______________________________________________
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12. Keputusan ujian air kencing


12.1 Tarikh : _________________________________________
12.2 Keputusan : positif negatif
REKOD SELIAAN B3
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


Bil ISU Tempat Tarikh Catatan

2. Penyertaan dalam aktiviti yang dianjurkan oleh pihak sekolah

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3. Pandangan secara umum terhadap ibubapa / penjaga klien

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REKOD SELIAAN B3
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MAKLUMAT PEMANTAUAN

BIL TARIKH MASA TEMPAT JENIS KAUNSELING TINDAKAN/CATATAN


REKOD SELIAAN B3
TANDATANGAN KAUNSELOR PENGESAHAN
PENGETUA

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