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FORM 1
Case No. ________________________Date of Intake________________________
Intake Form(Data may be obtained from the child and/or significant others.)
I. Identifying Data of the Child
Name: _________________________________ Alias, if any ________________
Sex: __________ Age: __________ Civil Status: ______________________
Date of birth: _____________________ Place of birth: ____________________
Religious Affiliation: _______________ If IP, please specify: _______________
Physical Disability (if any) ______________________________________________
Identifying marks (if any) _______________________________________________
Present Address: ______________________________________________________
_____________________________________________________________________
Provincial Address: ____________________________________________________
_____________________________________________________________________
Highest educational attainment: _________________________________________
Last school attended: __________________________________________________
Date/Year: ________________________ Status: ____ In-school ____ OSY
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Address of school: _____________________________________________________
2
II. Family Composition
A. Immediate Family
Name AgeRelationship to the
ChildCivil
Status AddressEduc.
Attainment
Occupation Monthly Income Remarks
B. Other household members
Name AgeRelationship to the
ChildCivil
Status AddressEduc.
Attainment
Occupation Monthly Income Remarks
C. Significant Others who may not be staying with the family
Name AgeRelationship to the
ChildCivil
Status AddressEduc.
Attainment
Occupation Monthly Income Remarks
3
4
D. Remarks (other relevant information on the child’s past and present)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
III. Circumstances of Referral(Information could be obtained from the law enforcement officer or accompanying party)
Name of referring party: ________________________________________________
Address: _____________________________________________________________
_______________________________________________________________
Contact No.: __________________________________________________________
Reason(s) for referral: __________________________________________________
Date of Referral: ______________________________________________________
Offense Allegedly Committed: __________________________________________
Date and Place Where Offense was allegedly committed: ____________________
_______________________________________________________________
Date of apprehension: _______________________ Place ________________
Apprehended By: _____________________________________________________
Name Designation
5
Agency/Address: ________________________________________________
_______________________________________________________________
Contact No.: ____________________________________________________
Name of Victim (if applicable) ___________________________________________
Age: ________________________ Sex: _______________________
Address: _______________________________________________________
_______________________________________________________________
Contact No.: ____________________________________________________
Relationship to the CICL __________________________________________
Name of Accompanying Person (if applicable): ____________________________
Relationship: _________________________ Age: ________________
Address: _______________________________________________________
_______________________________________________________________
Contact No.: ____________________________________________________
IV. Problem Presented
A. Law Enforcement Officer’s Report
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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_____________________________________________________________________
_____________________________________________________________________
B. Child’s Version
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Views of the child about the offense allegedly committed:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
V. Initial Assessment and Recommended Action_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
______________________________Name and Signature of Social
Worker
___________________________Date
7
8
FORM 2-A
Child’s Functioning/Characteristics
(Check Yes if Evident; No if Not Evident)
Child’s Functioning/Characteristics YES NO
*Physical
Appears healthy (malusog) _________ _________Looks sluggish (slow moving, mabagal kumilos) _________ _________Is full of energy (maliksi) _________ _________Others (specify, e.g. grooming, hygiene)
______________________________________________________________________________________________________
*Socio-emotional
Maintains good relationships with family and friends (maayos na pakikitungo sa pamilya) _________ _________
Expresses feelings in appropriate ways (nagpapakita ng angkop na damdamin) _________ _________
Shows remorse/regret (nagsisisi/nalulungkot) _________ _________Not at all affected (wala lang) _________ _________Is irritable and angry (magagalitin) _________ _________Answers questions willingly (maayos na sumasagot)
_________ _________
Hates parents/the world (galit sa mundo) _________ _________Has no feeling of guilt (dedma) _________ _________Others (specify)
______________________________________________________________________________________________________________________________
*Mental
Makes alibis and excuses (mahilig magpalusot) _________ _________Is clever (quick, skillful, mautak) _________ _________Has grandiose (big) notions about self (sobrang
bilib sa sarili) _________ _________Is knowledgeable about many subjects (maalam
sa mga bagay-bagay) _________ _________Remembers most events of childhood
(natatandaan ang mga nakaraan) _________ _________Asks questions and makes suggestions
(palatanong, palamungkahi) _________ _________
1
Child’s Functioning/Characteristics YES NOOthers (specify)
______________________________________________________________________________________________________________________________
*Behavioral
Demonstrates low tolerance (mainipin) _________ _________Runs away from family (stowaway, naglayas) _________ _________Chooses to be alone often (mapagsarili) _________ _________Takes risks/daring (lakas ng loob) _________ _________Respects authorities _________ _________Easily provoked to fight (pala-away) _________ _________Others (specify)
______________________________________________________________________________________________________________________________
*Spiritual
Believes in God/Allah (naniniwala sa Diyos) _________ _________Participates in religious activities (sumasama sa
mga gawaing simbahan) _________ _________Finds hope in living (may pag-asa) _________ _________Others (specify)
______________________________________________________________________________________________________________________________
*School Attendance and Performance
Has positive attitude about school (magandang pananaw sa pag-aaral) _________ _________
Is habitually late/absent (palaging late/absent) _________ _________Is willing to learn (Gustong matuto) _________ _________Finds schoolwork demanding (nahihirapan sa
pag-aaral)_________ _________
Is highly competitive (mahilig makipagtunggali) _________ _________Wants to go back to school (gustong bumalik sa
eskwelahan) _________ _________Has no interest in going to school (ayaw mag-
aral)Ashamed to go to school _________ _________Others (specify)
______________________________________________________________________________________________________________________________
*Aspirations (Mga hangarin)
Wants to be a (Gusto maging) _________________ _________ _________
2
Child’s Functioning/Characteristics YES NOWants to work hard to earn money (nagsusumikap kumita) _________ _________Wants to work to help parents/family (nagtratrabaho para makatulong sa pamilya) _________ _________Others (specify)
______________________________________________________________________________________________________________________________
*Involvement with drugs and volatile substances
Experiments with drugs/volatile substances (gumagamit ng bawal na gamut o sumisinghot ng rugby)
_________ _________
Finds drugs/volatile substance exciting (nasisiyahan sa bawal na gamot/rugby)
_________ _________
Spends money in drugs/rugby (gumagastos para sa bawal na gamot/rugby) _________ _________
Is aware about negative effects of drugs/volatile substances (may alam na makakasama ang bawal na gamot)
_________ _________
Others (specify)______________________________________________________________________________________________________________________________
*Involvement with vices (smoking, gambling, alcohol)
Gets drunk often (madalas maglasing) _________ _________Drinks alcohol occasionally (umiinom paminsan-minsan)
_________ _________
Spends money in gambling (gumagastos sa sugal)
_________ _________
Spends money in cigarettes (gumagastos sa sigarilyo)
_________ _________
Others (specify)______________________________________________________________________________________________________________________________
*Infractions with the law
Has previous barangay record (mayroong rekord sa barangay) _________ _________
Has previous police record (mayroong rekord sa pulis)
_________ _________
3
Child’s Functioning/Characteristics YES NOIf yes, identify specific offense(s): ___________________________________________
_____________________________________________________________________If arrested/detained, state number of days in detention: _________________________Place of detention: _______________________________________________________
_____________________________________________________________________Gets away freely from any violation (nakakawala sa mga kasalanan) _________ _________In and out of detention (labas-pasok sa kulungan)
_________ _________
Involvement with gangs, groups or fraternities _________ _________Others (specify)
______________________________________________________________________________________________________________________________
*Interest in pornographic/obscene materials, films
Has access to obscene materials (nakakakuha ng malalaswang babasahin/DVD/VCD) _________
_________
Spends money to buy these materials (gumagastos para sa malalaswang babasahin/DVD/VCD)
_________ _________
Enjoys sex-oriented films (nawiwili sa mga malalaswang pelikula) _________ _________
Spends money to watch x-rated films (gumagastos para manood ng x-rated) _________ _________
Others (specify)______________________________________________________________________________________________________________________________
*Remarks
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________Name and Signature Case Worker/Interviewer
4
__________________________Date
5
FORM 2-B
FAMILY FUNCTIONING CHECKLIST
Directions: Administer the checklist by interviewing the child or any of his significant others. Some information may be obtained through observation. This suggests that the checklist may not be completed in one sitting.
Check the appropriate column (Yes or No) to represent the respondent’s answer.
Family Functioning/Characteristics YES NO
1. Family lives in a quiet, wholesome community/ neighborhood. (Nakatira ang pamilya sa tahimik na lugar.)
_________ _________
2. Parents are often in-conflict. (Madalas mag-away ang mga magulang.) _________ _________
3. Parents are hardworking. (Nagsusumikap nang mabuti ang mga magulang) _________ _________
4. Family head has a decent work/occupation. (Maganda ang hanapbuhay ni tatay.) _________ _________
5. Parents are disappointed with one another. (Ang mga magulang ay nagsisisi sa kanilang pagsasama.)
_________ _________
6. Family lives in a hand-to-mouth subsistence. (Mahirap ang buhay ng pamilya.) _________ _________
7. Marriage is characterized by unpleasant relationships. (Pangit ang samahan ng mga magulang.)
_________ _________
8. Parents value their children. (Pinahahalagahan ng mga magulang ang kanilang anak.) _________ _________
9. Parents see hopes in their children. (Nagdudulot ng pag-asa ang mga bata.) _________ _________
10. Child is caught between conflicts of parents. (Bata ay naiipit sa awayan ng mga mgulang.) _________ _________
11. Family experiences marital conflicts. (Maraming gulo ang dinaranas ng pamilya.) _________ _________
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Family Functioning/Characteristics YES NO12. Parents often make the children their objects of
hostility. (Madalas mga ang napagdidiskitahan ng sama ng loob ng mga magulang.) _________ _________
13. Poor family conditions stimulate conflicts in parents. (Ang kahirapan ng pamilya ay nagdudulot ng mga alitan sa mag-asawa.) _________ _________
14. Parents try their best to achieve pleasant home atmosphere. (Sinikap ng mga magulang na maging maginhawa ang buhay ng pamilya.) _________ _________
15. Parents maintain order in the family. (Mahusay ang pamamalakad sa pamilya.) _________ _________
16. Father is trouble-maker. (Basagulero and tatay ng pamilya.)
_________ _________
17. Child often meets frustrations in the family. (Madalas makaranans ng pagkabigo ang bata sa pamilya.)
_________ _________
18. Parents have little trust in each other. (Mahina ang tiwala ng mga magulang sa isa’t-isa.) _________ _________
19. Child experiences physical comfort at home. (Nakakaranas ng ginhawa ang bata sa bahay.) _________ _________
20. Family enjoys regular meals daily. (Sapat ang pagkain ng pamilya sa araw-araw.) _________ _________
21. Child sees his father as the survival figure (Tingin ng bata sa kanyang tatay ay tanging pag-asa para mabuhay ang pamilya.)
_________ _________
22. Child is able to do things to take care of himself. (Napapangalagaan ng bata ang kanayng sarili.) _________ _________
23. Family encourages child to make decisions. (Pinapayagan ng pamilya na gumawa ng sariling desisyon ang bata.)
_________ _________
24. Parents have realistic expectations of child. (Makatotohanan ang pangarap ng mga magulang para sa kanilang anak.)
_________ _________
25. Child learns to fit in with the family lifestyle. 9Umaayon ang bata sa takbo ng buhay ng pamilya.)
_________ _________
26. Child has skills for coping and balancing the requirements of the environment. (May kakayahan _________ _________
2
Family Functioning/Characteristics YES NOang bata na tumugon sa pangangailangan ng karamihan.)
27. Child accepts restrictions and learns rules as part of growing. (Maluwag na sumusunod ang bata sa mga patakaran at pagbabawal.) _________ _________
28. Child develops positive self-esteem. (Maganda ang pagkakakilala ng bata sa kanyang sarili.) _________ _________
29. Parens get along well day-by-day. (Maayos ang samahan ng mga magulang.) _________ _________
30. Parents are consistent in their dealings with their children. (Maayos at di pabago-bago ang pagpapalaki sa mga bata.)
_________ _________
31. Family is often in pain. (Madalas makaranas ng hirap ang pamilya.) _________ _________
32. Family pain leads to poor parenting. (Ang hirap ng pamilya ay dahilan ng hindi magandang pagpapalaki sa mga bata.)
__________________
33. Child enjoys independence of his parents. (Bata ay binibigyan ng kaukulang laya ng magulang.) _________ _________
34. Child is unable to integrate an appropriate image of his own. (Hindi kaya ng bata ang maipakita ang angkop niyang pagkatao.)
_________ _________
35. Child feels he is left out. (Nadarama ng bata na parang balewala siya sa pmilya. _________ _________
*Remarks__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________Name and Signature Case Worker/Interviewer
__________________________Date
3
4
FORM 3-A
Name of Child: _____________________________________ Age: ______________Name of Center/Community: ________________________________________________
Test Booklet:
Index of Discernment
Directions:The following is a series of situations or activities about day-to-day living.
Analyze each situation or activity and determine if it is RIGHT or WRONG. Encircle the letter R or W to represent RIGHT or WRONG, respectively.
Examples:
Throwing garbage anywhere. (Pagtatapon ng basura kahit saan)R W
Drinking clean water. (Pag-inom ng malinis na tubig)R W
1. Reading a good book (Pagbasa ng magandang libro) R W
2. Respecting one’s parents (Paggalang sa magulang) R W
3. Running away from home and being astray (Paglayas ng bahay at pagpapalaboy-laboy)
R W
4. Smoking cigarettes (Paninigarilyo) R W
5. Cutting classes (Di pagpasok sa klase) R W
6. Believing in God (Paniniwala sa Diyos) R W
7. Destroying the properties of others (Pagsira sa gamit ng ibang tao)
R W
8. Cheating during examinations (Pandaraya sa eksam) R W
9. Quarreling with brothers and sisters (Pakikipag-away sa mga kapatid)
R W
10.Keeping the house clean (Pagpapanatiling malinis ang bahay)
R W
11.Shoplifting (Pagnanakaw sa tindahan/grocery/department store)
R W
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12.Eating with dirty hands (Pagkain na marumi ang kamay) R W
13.Treating someone cruelly (Pang-aapi sa kapwa) R W
14.Cruelty to animals (Pagmamalupit sa hayop) R W
15.Studying lessons well (Pag-aaral nang mabuti) R W
16.Coming home late at night (Pag-uwi ng gabing-gabi) R W
17.Playing very loud and disturbing music (Pagpapatugtog ng malakas at nakakaistorbong musika)
R W
18.Creating trouble in school (Panggugulo sa eskwelahan) R W
19.Taking care of personal belongings (Pag-aalaga sa sariling gamit)
R W
20.Going to church/place of worship and praying (Pagsimba at pagdarasal)
R W
21.Coming to school always late (Palaging huli sa klase) R W
22.Stealing (Pagnanakaw) R W
23.Discussing about bad and malicious things (Pag-uusap tungkol sa mga bagay na masasama at mapanira sa kapwa)
R W
24.Keeping good friends (Pagpapanatili sa mabubuting kaibigan)
R W
25.Arguing and fighting with parents and elders (Pakikipagtalo at pakikipag-away sa matatanda)
R W
26.Spending tuition money (Pagwaldas ng perang pambayad sa iskul)
R W
27.Keeping oneself healthy (Pagiging malusog) R W
28.Dropping out of school (Pagtigil sa pag-aaral) R W
29.Attempting to commit suicide (Tangkang magpakamatay)
R W
30.Obeying traffic rules (Pagsunod sa trapiko) R W
31.Getting high grades in school (Pagkakaroon ng mataas na marka)
R W
32.Doing responsible household chores (Paggawa ng gawaing bahay)
R W
33.Killing the neighbor’s pet (Pagpatay sa alagang hayop R W
2
ng kapitbahay)
34.Driving while drunk (Pagmamaneho nang lasing) R W
35.Doing a job well (Paggawa nang maayos na trabaho) R W
36.Disobeying parents (Pagsuway sa utos ng magulang) R W
37.Taking prohibited drugs (Pag-gamit ng droga o bawal na gamot)
R W
38.Coming home straight from school (Pag-uwi ng deretso sa bahay)
R W
39.Mother neglecting her family (Pagpapabaya ni nanay sa pamilya)
R W
40.Being dishonest (Pandaraya) R W
41.Having regular exercise for good health (Pag-eehersisyo para sa kalusugan)
R W
42.Avoiding trouble (Pag-iwas sa gulo) R W
43.Beating someone (Pananakit ng kapwa) R W
44.Helping to benefit a younger sibling (Pagtulong sa ikabubuti ng nakababatang kapatid)
R W
45.Volunteering in community work (Pagtulong ng kusa o boluntaryong pag-gawa)
R W
46.Staging a hold-up (Pangho-holdup) R W
47.Giving donations to charity (Pagtulong sa nangangailangan)
R W
48.Keeping the environment clean (Pagpapanatiling malinis sa kapaligiran)
R W
49.Disobeying traffic rules (Paglabag sa batas trapiko) R W
50.Having poor work habits (Hindi maayos na pagtratrabaho)
R W
51.Staying away from bad influence (Pag-iwas sa masasamang barkada)
R W
52.Doing something good for somebody (Paggawa ng mabuti sa iba)
R W
53.Doesn’t want to work (Ayaw magtrabaho/tamad) R W
54.Attending to the needs of the family (Pagtugon sa R W
3
pangangailangan ng pamilya)
55.Speaking ill of other people (Paninira ng kapwa) R W
4
KEY TO CORRECTION
1. R 21. W 41. R2. R 22. W 42. R3. W 23. W 43. W4. W 24. R 44. R5. W 25. W 45. R6. R 26. W 46. W7. W 27. R 47. R8. W 28. W 48. R9. W 29. W 49. W10. R 30. R 50. W11. W 31. R 51. R12. W 32. R 52. R13. W 33. W 53. W14. W 34. W 54. R15. R 35. R 55. W16. W 36. W17. W 37. W18. W 38. R19. R 39. W20. R 40. W
Interpretation of the result
Scores Description
45 – 55 --------------- Superior34 – 44 --------------- Above Average23 – 33 --------------- Average12 – 22 --------------- Below Average 1 – 11 --------------- Poor
5
FORM 3-B
Case Situations
Direction: The following case situations were formulated to find out what a child would do under a given situation and why he/she would choose to do so. Present the case situations to the CICL one at a time. Record the answer/s of the child. Also record the non-verbal responses of the child.
1. Natapunan ng softdrink ang damit mo ng isang pasahero sa jeep. Ano ang gagawin mo? Bakit?
2. Nilason ng inyong kapit-bahay ang inyong alagang aso. Ano ang gagawin mo? Bakit?
3. Napatid mo ang alambre ng kuryente sa kalye habang nanunugkit ka ng mangga. Ano ang gagawin mo? Bakit?
4. Nasira mo ang tubo ng gripo ng inyong kapitbahay. Ano ang gagawin mo? Bakit?
5. Napagtripan ng iyong barkada ang isang bagong salta sa barangay. Ano ang gagawin mo? Bakit?
6. Tumanggi ang iyong girlfriend na makipagtalik sa iyo. Ano ang gagawin mo? Bakit?
7. Pinahiya ng inyong kapitbahay ang iyong nanay. Ano ang gagawin mo? Bakit?
8. Pinilit ka ng iyong barkada na gumamit ng ipinagbabawal na gamot. Ano ang gagawin mo? Bakit?
9. Siniraan ka ng iyong kasamahan sa barangay. Ano ang gagawin mo? Bakit?
10. Naiinis ka sa mga kapatid mo dahil lagi nilang pinakikialaman ang mga gamit mo. Ano ang gagawin mo? Bakit?
11. Pinagagalitan ka ng iyong mga magulang dahil sa masasama mong barkada. Ano ang gagawin mo? Bakit?
12. Nagastos mo ang perang pambayad ng iyong nanay sa tindahan. Ano ang gagawin mo? Bakit?
13. Nasuklian ka ng sobra sa tindahan. Ano ang gagawin mo? Bakit?
14. Saksi ka sa pagnanakaw ng iyong kaibigan. Ano ang gagawin mo? Bakit?