Department of Social Welfare and Development Name of the Center: GENERAL INTAKE SHEET Dat Identifying information: A) (About the child) Nome of clien Nickname: Age: _Sex Address: Civi Status Date of Birth: Place of Birth Religious Affiliation Occupation: Highest Educational Attainment: Name of Schoo! Address of the Schoc Class Adviser. Case Category B.) Contact Person: Name. Age Sex Civil Status. Relationship with the client, Occupation/Source of income. Honhe Address {if applicable}, Office Adcress Contact No. I Circumstances of Referral: ¥ Description of the circumstances referral ¥ Source of Referral ¥ Reasons forthereferral II Problem Presented: Y Cite the situation the client is in, hence the child’s need of the agency's assistance IV, Family Composition: Name [Age | Relationship | Civil | Address | Educ. | Occupolion | Monthy | Remarks tothe child | status Attainment income, immediate Family ‘Other household members Significant others who may not be staying with the familyV. Background Information: (Description of the child, family and community) ‘Ad Chite's Description ¥ Description of the clients psychosocial history to include family Serious Accident ZL Victim of natural /man made disaster Victim of demotion = Victim,of apprehension Victim of sexual abuse fim of physical abuse —_L- Vietim'of verbal abuse With suicidal tendencies __— Acavired disability Mistaken identity ‘Others: (pls. Specify) ‘= Enduring life strain ‘© Everyday problems © life transition «Attachments © Skills © Resources ‘A) Major Life Events ‘Age Of | Feelings/Behavior towards the incident [+ or Onset Feelings [+ or) {_ Death of parents Happy ——/— Abandonment Contented ‘Separation from the Feeling of freedom + Belongingness + Hatred + Guilt + Independence = Rebellion Behavior: Stow away Withdrawal Iritable Unresponsive/possive Delinquent behavior Indulge in ilegal substance Stealing Snatching Begging Staying in the street Others (pls. Specify) Others (pls. Specify Cannot label feslinas/, Hions/Tear-eved, 8) Enduring Life Strain —L__Poverty Constant need to earn forthe family {Physical tiness (pis. Specify) M Malnourished Lack of education/educational opportunity Lack of recreational facilities Exclusion from school Exclusion from peers [with cisobott Feelings (+ or-) Happy Contented Feeling of freedom Belongingness Hatred Guilt Independence Rebellion Behavior: "Stow away + Withdrawal + _initabie‘Gihers (pis. Specify) Others ( =~ Unresponsive/passive * Delinquent behavior * Indulge in illegal substance Stealing Snatching Begging Staying in the street Others (pls. Specify) p's. Specify) Dropped out of school Gi) Everyday Problems| Finding food Feelings (+ or-) Finding clothes = Happy Finding shelter + Contented Finding faclities for personal + Feeling of freedom care + Belongingness Avoiding street violence + Hatred + Guilt + Independence + Rebellion Behavior: + Stow away + Withdrawal . + Initable + Unresponsive/passive ‘ + Delinquent behavior + Indulge in ilegal substance + Stealing + Snatching + Begging + Staying in the street + Others (pls. Specify) Others (pls. Specify) D) life Transition: Feelings (+ or] Moving from one + Hoppy neighborhood toonether + Contented changing peer group + Feeling of freedom Moving to another place of + Belongingness jesidence due 10 demotion + Hatred Moving to another place of + Guilt residence due lo disaster + Independence Moving from biological + Rebellion fomily to 0 kinship/foster placement Behavior Beginning romantic relationship + Stow away Beginning romantic relationship + Withdrawal ‘of parents (father has another farnily) + Iritoble Others (pls. Specify) + Unresponsive/passive . + Delinquent behavior + Indulgein tlegal substanceStaying in the street Others (pls. Specify) = Stealing = Snaiching + Begging Others (pls. Specify] Does not want father to Jeove them =) Developmental Changes: Early childhood 1-6 yrs, old TE school age 7-12 yrs. old T= Adolescence 13-18 yrs. old Child performs household tasks and takes care of siblings instead of playing and going toschool F) Normalization: Legalty/law enforcement (weak) = availabilty of = Commercial sex + Substance /ilegal drugs = Pomography materials to include video tapes + Red Houses Price - least expensive ‘Adverfising /sponsors presentation + Advertisement promoting liquors/cigorettes/clubs/red houses + Television shows = Movies = Printed materials community oeceptance * Source of income * Involve in actual trade / production role of culture (culturally accepted) smoking Drinking Abuse Gambling Iicit relationship Polygamous relationship Incest relationship Begging Rugby sniffing medio G,) Desired Effects Entertaining Lessens hunger Reduces emotional pein Reduces physical pain Increase eneray Feeling of belongingHi) Attachments: = Grandmother (Grand father aaa Uncle Neighbor Peer —— Cousin Schoolmate teacher Classmate (Others uy Skis Problem solving Coping skils Interpersonal relationship Survival skis ‘Communication skis Decision making skills, ‘vocational skis Comprehension Critical thinking Seif awareness (Others Dancing/Singina/ | Performing household chores/care aiving || II JJ) Resources Internal Resources Intelligence Education Sptituality Discipline Resourceful Respectful Obedient submissive Others Cooperative rpereaoge extemal Resources Fomily Other street children Peers Sireet educators Health services Vocational services Recreational services LGU staff at alllevels NGOs existing in the ‘communisFeopie’s Organization Civic organization Faith - based organization Others (pls. Specify) . Family Description/Characteristics: Description of the chila's family in terms of ‘© Family relationship in general Family upbringing / child rearing ‘© Values within the family Resources within the family © Parents feelings towards the incidence Family Description/Characterstics YES {Family Ives ino auiet, wholesome community/neighborhood. (Nakotira and pomilya sa tahimik ne luacr ZPovenis ore offen in confit, [Madolos mag-cway and mga_meaviona aoe crenieore hardworking [Nagsumikap nang mabuti ang raga magvang} 7 (grandfather) = Family heads hes o decent work/occupation (Maganda eng hanapbvhay i tatoy) 1 = Porenis are Gsappoinied with one another. (Ang mga maguions oy nagsiss so kanilang pagsasame. Z-Family fives in @ hand to mouth subsistence (Mahirap ang PunGy ng pamilya} 7 Mariage fs Characterized by unpleasant relationships. (Pansit eng samahan ng mac maguicng.) B:Pavenis valve their children [Pinchahalaganan ng mga magulang ang kanilang anak) F:Parenls see hopes in heir children, (Nagdudulot ng pag-asa ang mae bata} 70. child & caught belween conficis of parents (Bota ay nel sa, awayon ng mga maguiong) 71 Family experiences marital conflicts, (Maraming guio ang dincranos ng pamilya) 72 Parents offen make the children thelr objects of hostty. (Madales mac ‘pote ong nadidiskitahan ng sama ng loob na mga magulcng 73. Foor fornily concitions stimulate conficts in parents. (Ang kahropan ng ‘pamilya ay nagduduiot ng mgo clitan sa mag-asawe TH Parents try heir best to achieve pleasant home afmosphere. (Sinikap ng igo mogulong na nagaing maginhewe, cng buhey ne oamilya) Awareness of the problem (initial impression of the problem its causes) > Readiness and willingness (strength / potential / weaknesses) > Ability to do something about the problem (who and what are the resourcesVIL. _ Intervention Plan Problems/ | Objectives [Activities | Responsible | Time | Expected _ | Progress Needs/Issues Person Frame | Output —_| Indicators Concerns Identified Vill, RECOMMENDATIONS: Prepored by: Social Worker Reviewed/Noted by: Supervisor