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    Intake Sheet Long

    Uploaded by

    JanJan Cabusbusan
    This document contains forms and documentation related to intake and case management for boys admitted to a home called "Dalayunan" in Iloilo City, Philippines. The forms collect identifying information about admitted boys, including name, age, family, circumstances for admission, assessments, and checklists of required documents. Progress updates are also documented with daily activities and notes. The forms and documents aim to properly intake and manage the cases of boys admitted to the home.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    Intake Sheet Long

    Uploaded by

    JanJan Cabusbusan
    41 views8 pages
    This document contains forms and documentation related to intake and case management for boys admitted to a home called "Dalayunan" in Iloilo City, Philippines. The forms collect identifying information about admitted boys, including name, age, family, circumstances for admission, assessments, and checklists of required documents. Progress updates are also documented with daily activities and notes. The forms and documents aim to properly intake and manage the cases of boys admitted to the home.

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    Intake Sheet Long.xls

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    This document contains forms and documentation related to intake and case management for boys admitted to a home called "Dalayunan" in Iloilo City, Philippines. The forms collect identifying information about admitted boys, including name, age, family, circumstances for admission, assessments, and checklists of required documents. Progress updates are also documented with daily activities and notes. The forms and documents aim to properly intake and manage the cases of boys admitted to the home.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    41 views8 pages

    Intake Sheet Long

    Uploaded by

    JanJan Cabusbusan
    This document contains forms and documentation related to intake and case management for boys admitted to a home called "Dalayunan" in Iloilo City, Philippines. The forms collect identifying information about admitted boys, including name, age, family, circumstances for admission, assessments, and checklists of required documents. Progress updates are also documented with daily activities and notes. The forms and documents aim to properly intake and manage the cases of boys admitted to the home.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 8

    "DALAYUNAN"...

    A home for boys


    City Social Welfare and Development Office
    City Government of Iloilo
    Zone 3 Bo Obrero, La Paz, Iloilo City
    Date Admitted:
    Date of Intake:
    Case Filed:
    Case No./s:
    Frequency of Admission:
    Contact Number:

    Date of Birth:
    Age Upon Admission:
    YRS MO DAYS

    INTAKE FORM
    (Data may be obtained from the child and or significant others)

    I. Identifying Data of the child


    Name:
    Alias:
    City Address:
    Provincial Address:
    Gender/Civil Status:
    Date & Place of Birth:
    Religious Affiliation:
    Highest Educ. Attainment:
    Last School Attended:
    Physical Disability:
    Identifying Marks in the body:
    Offense Allegedly Committed:
    Commiting Court:
    Date of Court Order:

    II. Family Composition


    (A. Immediate Family)
    Highest Educ. Monthly
    Name Age Civil Status Occupation
    Attainment Income

    Father:
    Mother:

    Guardian:
    Guardian:
    Siblings 1)
    2)
    3)
    4)
    5)
    6)
    7)
    8)
    9)
    10)
    11)
    12)

    (B. Other Family Members)


    Highest Educ. Monthly
    Name Age Civil Status Occupation
    Attainment Income

    1)
    2)
    3)
    4)
    (C. Significant Others)
    Highest Educ. Monthly
    Name Age Civil Status Occupation
    Attainment Income

    1)
    2)
    3)
    4)
    (D. Other related information about the child)
    age first tried to smoke cigarette _________________ type of cigarette ___________________________________
    how many sticks per day _____________________ influence by _______________________________________
    age first tried to drink liquor ___________________ type of liquor ___________________________________
    how many bottles per week ___________________ influence by _______________________________________
    age first tried rugby _______
    how many times per week ______________________________ influence by ________________________________________
    age first tried marijuana _________________________

    how many times per week ______________________ influence by ___________________________________________

    age first tried shabu ___________________________________________

    how many times per week ______________________ influence by ___________________________________________

    age first tried to have girlfriend ________________________ many GF you have ________________

    age first tried to have intimate experience with girlfriend ________________ Out _________ only ____________ tried

    what is your dream when you're a child __________________________________

    do you you can materialize your dream _______________________________________________________________________________

    ____________________________________________

    are you parents together _____________________________________________________

    what you like about your father? _____________________________________________________

    what you like about your mother? _____________________________________________________________________________________

    __________________________________________________

    what you like about your siblings? _____________________________________________________________________________________

    _____________________________________________________

    III. Family Socio-Economic Background


    -
    -
    -
    -
    -
    -
    -
    -
    -

    IV. Circumstances of Referral (information can be obtained from the law enforcement or accompanying party)

    Name of referring party and its address_________________________________________________________________________________________

    Contact Number and reason for referral_______________________________________________________________________________________

    Date of Referral and offense allegedly cmmitted_______________________________________________________________________________

    Date & Place of Where Offense allegedly committed__________________________________________________________________________

    Date & Place of Apprehension________________________________________________________________________________________________

    Apprehended by_____________________________________________________________________________________________________________

    Investigator/Agency/Address/Contact No.:____________________________________________________________________________________

    Name of victim/age/sex/address_______________________________________________________________________________________________

    Name of accompanying person/relationship with CICL/Contact No.:___________________________________________________________

    V. Problem Presented
    (A. Law enforcement Officer's Report)
    (B. Child's version of the case)

    (C. Views of the child about the case)

    VI. Initial Assessment

    VII. Recommendation

    Prepared by:
    "DALAYUNAN"… A home for boys
    City Social Welfare and Development Office
    Zone 3 Bo Obrero, La Paz, Iloilo City

    UPDATE REPORT
    Name:
    Alias:
    City Address:

    DETAILS:
    DATE ACTIVITY

    Prepared by:
    "DALAYUNAN"...A home for boys
    City Social Welfare and Development Office
    City Government of Iloilo
    Zone 3 Bo Obrero, La Paz, Iloilo City

    0
    Date Admitted 0
    Date of Birth 0
    Name:

    CHECKLIST OF DOCUMENTS
    FOR NO CASE FILED/DROP-INS
    TURN OVER MINOR SLIP FROM WCPD
    BLOTTER REPORT
    REFERRAL LETTER FROM REFERRING DISTRICT SOCIAL WORKER
    MEDICAL CERTIFICATE
    CERTIFICATE OF ADMISSION
    INTAKE SHEET
    ASSESSMENT OF THE CASE BY THE REFERRING SOCIAL WORKER
    (If client needs to stay longer at the center)
    CERTIFICATE OF LIVEBIRTH
    PICTURE OF MINOR
    MONTHLY PERFORMANCE EVALUATION OF CLIENT'S PROGRESS
    INVENTORY OF ADMISSION
    OTHERS

    FOR CASE FILED/FOR INSTITUTIONAL DIVERSION


    TURN OVER MINOR SLIP FROM WCPD
    BLOTTER REPORT
    REFERRAL LETTER FROM REFERRING DISTRICT SOCIAL WORKER
    MEDICAL CERTIFICATE
    CERTIFICATE OF ADMISSION
    INTAKE SHEET
    JUDICIAL AFFIDAVIT
    INFORMATION OF THE CASE
    ASSESSMENT OF THE CASE BY THE REFFERING SOCIAL WORKER
    CERTIFICATE OF LIVEBIRTH
    PICTURE OF MINOR
    MONTHLY PERFORMANCE EVALUATION OF CLIENT'S PROGRESS
    INVENTORY OF ADMISSION
    OTHERS
    0
    DELACRUZ<
    "DALAYUNAN"… A home for boys
    City Social Welfare and Development Office
    Zone 3 Bo Obrero, La Paz, Iloilo City

    UPDATE REPORT
    Name:
    City Address:
    Specify Activity:
    Date & Time:
    DETAILS:

    Prepared by:

    UPDATE REPORT
    Name:
    City Address:
    Specify Activity:
    Date & Time:
    DETAILS:

    Prepared by:

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