GENERAL INTAKE SHEET

CONFIDENTIALITY: This data collection activity is authorized by the Department of Social Welfare
and Development (DSWD).
No data/ information collect thru this activity can be used for taxation purposes

Date of Interview: March 13, 2023 Time Started: 10:45 A.M.

PART I. Personal Identification

Name of Client Descallar Ram Vincent P

Last Name First Name Middle Name
Religion Roman Catholic
Present Address
Region CARAGA Region 13
IP Membership N/A Province Agusan del Norte
City/ Municipality Butuan City
Barangay Libertad
Purok/Street No. Purok 9A

Part II. Family Composition

Currently
Li Relation Sex Attending
ne ship to (1- Age (as Birthdate Highest School
No Middle the M of last (mm/dd/yyyy Marital Educational (1-Yes 2- Primary
. Last Name First Name Name Grantee 2-F) bday) ) Staus Attainment No) Occupation
(client
have no client have no College client have
1 Descallar Ryan Father 1 info.) info.) Nulled Gaduate N/A no info.)
College
2 Pahama Marynold Testa Mother 2 39 12/28/1985 Nulled Graduate N/A Freelancer

Accomplished by:

JENNIFER SAMULDE ARCOSA

Signature over Printed Name of the Social Worker

Part III: Identifying Information

Name of the Client: Ram Vincent P Descallar

Sex: Male

Civil Status: Single

Religion: Roman Catholic

Ethnic Affiliation: Cebuano

Age: 19

Birth Date: December 7, 2003

Place of Birth: Doongan, Butuan City, Agusan Del Norte

Present Address: Purok 9A Brgy. Libertad, Butuan City, Agusan Del Norte

Highest Educational Attainment: 1st year college student

Present Occupation: N/A

Income: N/A

Part IV: Presenting Problem

Ram, 19, a 1st year BSSW student at Caraga State University. He was referred by the Faculty
Instructor to the social work student because of his poor academic performance. Ram have received
his gardes for last semester in which he had passed the general courses but shows problem on his 2
major courses as he failed to achieve the passing grade.During the gardes assessment in enrollment he
had been warned because of his grades. Ram with his other classmates have been involve also in the
cheating incident last sem.

Accomplished by:

JENNIFER SAMULDE ARCOSA

Signature over Printed Name of the Social Worker