CRISIS INTERVENTION SECTION

(FIELD OFFICE XII)

DSWD-PMB-GF-011 | REV 00 / 30 SEPT 2022

GENERAL INTAKE SHEET

MAARING MAGPATULONG SUMAGOT SA DSWD PERSONNEL

QN: PCN: Time Start: Date: MM DD YYYY

New Returning On-Site Walk-in ✘ Referral Off-Site

IMPORMASYON NG BENEPISYARYO (Beneficiary’s Identifying Information)

Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)
MM-DD-YYYY
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Marital Status Trabaho (Occupation) Buwanang Kita (Monthly Salary)

IMPORMASYON NG KINATAWAN (Representative’s Identifying Information)

Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)
MM-DD-YYYY
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Marital Status Trabaho (Occupation) Buwanang Kita (Monthly Salary)

Relasyon sa Benepisyaryo (Relationship to the Beneficiary) Time End:

Huwag susulatan ang DSWD lamang ang pwede gumamit (Do not write below this part for DSWD's use only)
Beneficiary Category Social worker's Assessment
Target Sector: Specify Sub-Category

FHONA Solo Parents

WEDC Indigenous People
YOUTH Recovering Person who used drugs
PWD 4PS DSWD Beneficiary
SC Street Dwellers
PLHIV Psychosocial/Mental/Learning Disability
Stateless Person/Asylum Seekers/Refugees
✘ Others:
KOMPOSISYON NG PAMILYA (Family Composition)
Buong Pangalan Relasyon sa Benepisyaryo Edad Trabaho Buwanang kita
(Complete Name) (Relationship to the Beneficiary) (Age) (Occupation) (Monthly Salary

Material Assistance:
✘ Financial Assistance: Psychosocial Support: Referral:
Family Food Packs __________
Medical ✘ Food Assistance Psychological First
Other Food Items __________
Funeral Cash Assistance Aid (PFA)
Transportation for Other Support
Hygiene & Sleeping Kits
Social Work __________
Assistive Device & Technologies Counseling
Educational Services
Provided Amount Fund Source
1 3000 E-AICS
2

"I declare under oath that I personally accomplished the GIS Form and all the
information provided herewith is TRUE, CORRECT, VALID, and COMPLETE pursuant
to existing laws, rules, and regulations of the Republic of the Philippines. I authorized
the Agency Head/Authorized Representatives to verify and validate the contents stated Interviewed by: Reviewed & Approved by:
herein. I also AGREE that any MISINTERPRETATION and information/acts to
DEFRAUD the government, including attached documents, shall cause the filing of
appropriate case/s against me."

JULIETA F. CLAVEL, RSW

Buong Pangalan at Pirma Social Worker Approving Authority
(Signature over Printed Name) Social Welfare Officer II SWO III/SWADT Cotabato Province

_______________________________________________________________________________________________
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DSWD Field Office XII , Purok Bumanaag, Brgy. Zone III, Koronadal City, South Cotabato, Philippines (9506)
Website: http://www.dswd.gov.ph Tel Nos.: (083) 228 - 2086 Telefax: (083) 228 - 2086
 CRISIS INTERVENTION SECTION
(FIELD OFFICE XII)
DSWD-PMB-GF-013 | REV 00 / 30 SEPT 2022

CERTIFICATE OF ELIGIBILITY
(Financial Assistance)

QN: PCN: Date:

New Returning On-Site Walk-in ✘ Referral Off-Site

Mal Fem
This is to certify that, , e ale
Kumpletong Pangalan (First name, Middle name, Last name) Kasarian (Sex) Edad (Age)

and presently residing at

kumpletong Tirahan (Complete Address)

has been found eligible for assistance after the assessment and validation conducted, for his/herself or through the representation of his/her

Relasyon ng Kinatawan sa Benepisyaryo (Relationship of the Representative to Beneficiary) Buong Pangalan ng Benepisyaryo (Name of Beneficiary)

Records of the case such as the following are confidentially filed at the Crisis Intervention Division (CID)

✘ General Intake Sheet Medical Certificate/Abstract Discharge Summary Death Summary

Laboratory
✘ Valid I.D. Presented Prescriptions
Request
Referral Letter
Statement of Account Charge Slip Social Case Study Report
4PS DSWD I.D. Treatment Protocol Funeral Contract Others
Justification Quotation Death Certificate

The Client is hereby recommended to receive assistance for

in the amount of Php. CHARGEBLE AGAINST: PSP 2023

(Year)

Conforme: Prepared by: Approved by:

JULIETA F. CLAVEL, RSW, MASW

Beneficiary/Representative Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Acknowledgement Receipt

Date: MM DD YYYY

THREE THOUSAND PESOS ONLY Php 3000

✘ Financial Assistance
(Amount in words)

Medical Assistance Transportation Assistance Food Assistance

Funeral Assistance Educational Assistance Cash Assistance for Support Services

Tinanggap ni: Binayaran ni: Sinaksihan ni:

REA G. PORTALIO
Beneficiary/Representative RDO / SDO SWO / ADMIN
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

*E.O 163 series 2022

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DSWD Field Office XII , Purok Bumanaag, Brgy. Zone III, Koronadal City, South Cotabato, Philippines (9506)
Website: http://www.dswd.gov.ph Tel Nos.: (083) 228 - 2086 Telefax: (083) 228 - 2086