GENERAL INTAKE SHEET

Date of Interview: _________________ Time Started: ___________ Time Ended: _________

(mm/dd/yyyy)

CONFIDENTIALITY: This data collection activity is purely for school requirement purposes. NO data/information collected shall be
shared to the public otherwise legal implication shall apply base from the data privacy act.

Part I. Household Identification

Name of the Client
Quibol Charel Rafal
Last Name First Name Middle Name Ext. (Sr./Jr./III)

4. Religion ROMAN CATHOLIC 6. Present Address Puro, Caoayan, Ilocos Sur

(refer to codes in Annex 1)
Region I
Province ILOCOS SUR
5. IP Membership _____________________
City/Municipality CAOAYAN
(refer to codes in Annex 1)
Barangay PURO
Purok/Street No. _______________________

Part II. Household Composition (Include here the client; Use additional sheets if necessary)
Currently
Relationship to Age Birthdate Highest
Full Name Attending
Line No. the Client Sex (as of last (mm/dd Marital Status Educational Primary Occupation Remarks
(Last, First, Middle) School
(0 – if the Client) b-day) /yyyy) Attainment
(Yes/No)

QUIBOL, F 18 01/23/2 SINGLE YES

1
CHAREL R. 003
2

10

III. Problem:
HAVING NO PRACTICAL KNOWLEDGE BECAUSE OF THIS ONLINE CLASS AND
EXPERIENCING STRUGGLES IN OUR MENTAL HEALTH.
Counselling Plan

Name of the Client

Over-all Goal:

Start Date of Coverage End Date of Coverage

Responsible Resources Expected
Concern/Issues/Needs Activities /Actions Timeframe
Person Needed Outcome
Beginning Phase
E.g.

Intake Conduct Interview October 5, 2021  Social Work  Private  Primary

Counsellor counselling information of
 Client room the client
 Recording
tool
 Intake sheet

Middle/Implementatio
n Phase
e.g. Exploring the Conduct counselling Otober 25, 2021  Social Work  Private Problem Tree of
underlying and working Counsellor counselling the client
problems  Client room
 Recording
tool

e.g. Medical Assistance Referral October 30, 2021 Referral Tool Addressed Medical
for Brother Juan 1. Social Work Needs
Counsellor
2. Client
Ending/Termination
Phase
e.g. Assessment of the Pre-Termination activity; January 10, 2021  Private Case Summary
Social functioning of the Motivating through 3. Social Work counselling
client counselling Counsellor room
4. Client  Recording
 tool

Prepared by:

_____________________________
Name of Student and Signature