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Initial Intake Form

This document is an intake form used by the office of the Barangay Captain in Talisay City, Cebu Province, Philippines. The form collects personal information about clients, including their name, age, address, education, and referring party. It also gathers family background details and documents the reason for referral, which could include issues like human trafficking, child exploitation, abuse, or other types of exploitation. Finally, it has a section for initial facts gathered about the client's case.

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Barangay Lawaan-ll
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89 views2 pages

Initial Intake Form

This document is an intake form used by the office of the Barangay Captain in Talisay City, Cebu Province, Philippines. The form collects personal information about clients, including their name, age, address, education, and referring party. It also gathers family background details and documents the reason for referral, which could include issues like human trafficking, child exploitation, abuse, or other types of exploitation. Finally, it has a section for initial facts gathered about the client's case.

Uploaded by

Barangay Lawaan-ll
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines

Province of Cebu
City of Talisay
Barangay Lawa-an II
Tel. no. 272-4700

OFFICE OF THE BARANGAY CAPTAIN

INITIAL INTAKE FORM


Case No.
I. Personal Data
Name : __________________________________ Nickname : ___________
Birthdate : __________________________________ Age : ___
Birth Place: __________________ Contact # : ___________
Home Address : ___________________________________________________________
Educational Attainment : ______________________________
Referring Party : _____________________ Contact # : ___________

II. Family Background


Name Relationship to Age Educational Source of
Client Attainment Income

III. Reason for Referral:


_____ Trafficking in Persons, for the purpose of:
_____Sexual Exploitation ______Forced Labor or Slaverly
_____Sale of Organs ______Armed Activities
_____Other types of exploitation,specify____
_____Child Sexual Exploitation:
_____Child Trafficking ______Child Prostitution
_____Child Pornography ______Child Labor
_____Child Abuse:
_____Physical Abuse ______Sexual Abuse
_____Verbal Abuse ______Psychological Abuse
_____Other types of abuse, specify_____

IV. Initial Facts Gathered


________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Prepared by: Noted By:


THERESA BAÑES JR. HON. JOSE EDWIN R. ETCOBANEZ
Barangay Focal Barangay Captain

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