Quisioner Home Visit

Nama Siswa : Kelas :

Nama Konselor : Tgl Pelaksanaan:

Wali Kelas : jenis Masalah :

Alamat : No HP/Tlp :

1. Perilaku siswa sebelum treatment (diisi sebelum home visit)

...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
2. Bentuk kesepakatan perlakuan di rumah dan di sekolah (diisi sebelum home visit)
a. Di rumah Dilaksanakan
Ya Tidak
 .......................................................................................... ............ .............

 .......................................................................................... ............. . ...........

 .......................................................................................... ............. . ...........
 .......................................................................................... ............. .............

b. Di sekolah Dilaksanakan
Ya Tidak
 .......................................................................................... ............ .............

 .......................................................................................... ............. . ...........

 .......................................................................................... ............. . ...........
 .......................................................................................... ............. .............
3. Perkembangan perilaku siswa pasca terapi

Di rumah Di sekolah
a. a.
b. b.
c. c.
d. d.
e. e.

4. Follow Up

Di rumah Di sekolah
a. a.
b. b.
c. c.
d. d.
e. e.

5. Kesimpulan
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

Mengetahui, Surabaya, ..................................

Guru BK Wali Murid

__________________________ ________________________