School

District/ Division

Period of Coverage

REPORTING FORM 1

Female Male
Indicators TOTAL
10-14 15-19 Total 10-14 15-19 Total

Number of adolescents screened with Rapid Psychosocial

1
Questionnaire (Rapid HEEADSSS)

1a Number of students with psychosocial concerns based on

Rapid HEEADSSS
abuse and safety
Stow-away behavior
Bullying
Suicidal ideations
Smoking / vaping
Alcoholic beverage drinking
Illicit drugs
Experience of romantic relationship
Sexual encounter
Sexual coercion/ abuse
Pregnancy/ Parenthood
Needs help/
Number of adolescents who underwent Seeks counseling
comprehensive
2 psychosocial evaluation
2a Psychosocial risks identified
(COMPREHENSIVE/FULL throughINTERVIEW)
HEEADDSS comprehensive
interview
dysfunctional family
Bullying
Out of School
Learning disabilities
Eating disorders
Internet overuse/ Internet gaming disorder
Smoking exposure/ use/ abuse
Alcohol drinking exposure. Use/abuse
Mental health concerns
Abuse
Gender identity concerns (LGBTQIA)
Risky sexual behaviors
Physical risk behaviors (motorcycle, driving without license)
Teen parent
Others_____________________
Others_____________________
Others_____________________
3 TOTAL NUMBER OF ADOLESCENTS WHO Followed up
4 TOTAL NUMBER OF INTERNAL REFERRALS
Guidance counselor
School nurse
School doctor
Child protection committee
School principal
Others_____________________
Others_____________________
Others_____________________
5 TOTAL NUMBER OF EXTERNAL REFERRALS
Partner primary facility
Barangay
Hospital
DSWD/ Social worker
TESDA
Others: __________________
Others: __________________
Others: __________________
Others: __________________
6 REASONS FOR EXTERNAL REFERRAL
Reason 1 ________________
Reason 2 ________________
Reason 3 ________________
Reason 4 ________________
Reason 5 ________________
Reason 6 ________________

Accomplished by: Noted and Verified by:

Name/ Designation Date Name/ Designation Date