INTAKE SHEET

I. Identifying Data
Name James
Age 24 years old
Date of Birth December 30, 1999
Place of Birth Barangay Libertad, Gingoog City
Civil Status Single
Religion Roman Catholic
Nationality/Citizenship Filipino
Residence Address P-3 Barangay Libertad, Gingoog City
Educational Attainment First-year college level
Present Occupation N/A
Monthly Income N/A

II. Household Composition:

Name Relation to Age S Educational Health Occupation Income
Interviewee e Attainment
x
1.Isidro Father 58 M High School Norma Farmer 500
Level l
2.Marita Mother 46 F High School Norma House 9,000
Level l worker
3.Christian Siblings 17 M Grade 12 Norma Student None
Dave Senior High l
School
4.Kathy Jane Siblings 19 F First-year Norma Student None
college l

III. Family Background and History

(You may ask here, about their relationship, the authority value in their family, family
dynamics, and communication. Some of the values they acquired from their family. If the
problem is about family conflict or anything, you may try to ask more but be sensitive
enough. Always be polite and try to be observant and listen carefully as to where you can
probe more)

There are 5 members of the family, 1 brother and 1 sister and his mother and
father. They are the family that is enough to sustain their daily need. And they have a
conservative parent and a respectful family that they have. The one that I interviewed is
the oldest among the three siblings and he is a kind of jolly person and respectful.

IV. Presenting Problem:

The client, Mark James, 24 years old is an out-of-school youth seeking for help of
being drug dependent that cause him problem of my interviewee is drug dependent which
causes him of being high and aggressive towards others.

V. Background of the Problem:

(Brief overview about why the problem is existing at this time, or how long has it been
existing, who are involved and how is it going?)

His problem is still existing currently because of he is still likes taking or using
drugs, it make him high and aggressive and do what ever he wanted to do. It has been
existing for 2 years of taking this drugs because it is the only way to feel that he has no
problem. And it is still existing because all of his friends are also taking the illegal drugs
that’s why he continue it currently.

MARK JAMES LISBOA

Name and Signature of Interviewee
02/23/24
Date

Initial Assessment:
(Make a causal statement here, re: why the problem is existing through personal,
structural and societal levels)

The problem still exists through personal because if he is not taking drugs when
he has a problem with something, he becomes anxious and thinks of a way to take drugs
and sometimes he thinks of stealing money from his parents. On a structural level, the
problem still exists because when his family makes him stop his studies and kicks him
out of their house that makes him trigger more to take drugs so that all of what he feels
might gone. On the societal level, the problem still exists because all of his friends and
relatives take illegal drugs making him forget all the problems that he has, and be active
more in all of what he has to do.

Recommendation:
(As to your professional judgment, what could be the possible intervention you can
recommend to help your interviewee solve or if not at least ease his/her current situation?
What are the strengths and weaknesses of your interviewee that could be of help, to
realize it.)
The possible intervention that I can give to him is to recommend him to a
rehabilitation center so that it can help him control the needs of being a drug dependent
and to help him avoid thinking that drugs are the only solution that the problems of life
will be solved. Also, after he passes the rehabilitation I recommend him in going back to
school so that he will not be manipulated or convinced by his friends and relatives to be
drug dependent again.

MICKO P. BANGOT
Social Work Student
(Signature Over Printed Name)