7/23/2019 7.16 Format Alih Tangan Kasus

1/1

SMP ISLAM AL-AZHAR KELAPA GADING JAKARTA

FORMAT

ALIH TANGAN KASUS

No. DokNo. RevisiNo. TerbitTgl BerlakuHalaman

: F/BK/16: 00::: 1 dari 1

ALIH TANGAN KASUS

Nama Siswa : ...................................................................................

Kelas : ...................................................................................

Jenis Kelamin* : L / P

Waktu : ...................................................................................

Pemberi Rujukan : ...................................................................................

Pihak Rujukan* : Dokter/ Polisi/ Biro Psikologi/ Lain-lain ......................

Bidang : ...................................................................................Nama Petugas Pihak Dirujukan : ...................................................................................

Masalah Siswa : ...................................................................................

.....................................................................................

.....................................................................................

.....................................................................................

Data yang Dilampirkan : ...................................................................................

.....................................................................................

.....................................................................................

Hasil Rujukan : ...................................................................................

.....................................................................................

.....................................................................................

.....................................................................................

Evaluasi dan Tindak Lanjut : ...................................................................................

.....................................................................................

.....................................................................................

Catatan: * Pilih salah satu

Mengetahui, Jakarta, ........................................

Kepala Sekolah Koord. Guru Bimbingan Konseling

SMPI Al-Azhar Kelapa Gading SMPI Al-Azhar Kelapa Gading

Drs. H. Asmawi, M.Pd Dra. Kholilah

NIP. 343974 264720 0 002 NIP. 363574 664830 0 062