Appendix A

(Name of Center)

(Address)

ADMISSION SLIP
___________________
Date

This is to certify that I received ________________________________________________________,

(Name of Client)
________ referred by _________________________from_________________________________________,
(age) (Agency) (Address)
this __________________ day of _______________________________ 200_____ for temporary shelter,
proper care and disposition at _______________________________________________________________.
(Name of Center)
__________________________
Social Worker
__________________________
Supervising Social Worker

Approved by:

________________________________
Center Head

__________________________
Date

I hereby authorize the administration and staff of ________________________________________

(Name of Center)
to decide on matters concerning the welfare/rehabilitation of my __________________________including:
(Relationship to CICL)

1. Medication, hospitalization, surgery and other matters related to his illness that may occur during his
stay at the center.
2. Social and recreational, educational and religious activities in relation to his rehabilitation.
3. Attendance at court hearings or preliminary investigations and other related activities.

________________________________________ __________________________
Signature of Parents/Guardians/Referring Party Date
 Appendix B

(Name of Center)

(Address)

INTAKE SHEET
Date Admitted:
Case No.
Status: Please Check: Admission: Re-Admission:
Referring Party:

DATA ABOUT THE CHILD:

Name :
(Given Name) (Middle Name) (Family Name)
Nickname/ Alias :
Birthdate :
Birthplace :
Religion :
Educational Attainment:
School/Year Last Attended:
Address of the School:
City Address:
Telephone/Mobile Phone No.
Provincial Address:
Physical Condition: (Any reported illness/ disabilities):

CONTACT PERSON:
Name :
(Given Name) (Middle Name) (Family Name)
Age:__________ Civil Status:________________ Relationship: (Specify)_____________________________
City Address:
Telephone/Mobile Phone No.:
Occupation/ Work:
Office/Work Address:
Telephone/ Mobie Phone No. :
FAMILY COMPOSITION:
Name Age Relationship Civil Educational Occupation Income Remarks
to Minor Status Attainment e.g.
disabled,
OCW, with
other
family

PROBLEM PRESENTED:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
______________________________________________________________________________________.

SIGNIFICANT OBSERVATION: (Physical, Behavioral, Strengths, Weaknesses):

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
______________________________________________________________________________________.

CIRCUMSTANCES/ BACKGROUND SURROUNDING THE PROBLEM:

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
______________________________________________________________________________________.
PLAN OF ACTION/ RECOMMENDATIONS:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
______________________________________________________________________________________.

______________________________
Client’s Signature/ Thumbmark

______________________________
Date

Prepared by:

__________________________
Social Worker

__________________________
Date

Supervised by:

_______________________________
Supervising Social Worker

_______________________________
Date

Reviewed & Noted by:

________________________________
Center Head

_____________________
Date
 Appendix C

Social Case Study Report

Case No.

Date:

I. Identifying Data of the Child

Name: Alias, if any:

Sex: Age: Civil Status:

Date of birth: Place of birth:

Religious Affiliation: If IP, please specify:

Highest educational attainment:

Last school attended:

Date/Year: Status: □ In-school □ OSY

Address of school:

Health Condition Disability, if any

Present Address:

Provincial Address:

II. OFFENSE COMMITTED by the CHILD

Type of offense:

Date of Apprehension Place

By Whom Address

Name of Victim Address

Date of Referral to Social Worker

Name & Address of Referring Party

Status of Case
II. Family Composition

A. Immediate Family

Name Age Relationship Civil Status Address EducAttainmt Occupation Monthly Remarks
to Child Income

B. Other Household Members

Name Age Relationship Civil Status Address EducAttainmt Occupation Monthly Remarks
to Child Income
C. Significant others who are not living with the family

Name Age Relationship Civil Status Address EducAttainmt Occupation Monthly Remarks
to Child Income

D. Remarks (other relevant information on the child’s past and present)

III. PROBLEM PRESENTED

▪ description of the child’s problem/s at intake/first contact with the social worker which
include physical, social, emotional/psychological condition of the child;
▪ accompanying person/guardian, if any or whether parents have been contacted and
their reactions to the situation & the child;
▪ nature/circumstances of apprehension, cause/factors leading to the offence,
frequency/severity of offence;
▪ action taken by victim against the child;
▪ action taken by concerned authorities e. g. barangay, if any; and
▪ reason for referral and status of case.

IV. BACKGROUND INFORMATION

A. THE CHILD’S FUNCTIONING

▪ level of physical, social, mental and emotional development and if appropriate with
his/her age and behaviour; has age been confirmed by documents? what are the
results of the physical and mental health examinations conducted? sexual
orientation?
▪ personality characteristics including attitudes towards authority and society; ability
to communicate his/her thoughts and feelings; coping with stress and problem-
solving skills; comprehension, critical thinking and decision-making; creativity,
spirituality and degree of self-awareness of his/her potentials/strengths and
limitations/weaknesses;
▪ school attendance and performance; plans and aspirations;
▪ relationship with parents, siblings, and other members of the family; violence and
abuse in the family; from child’s point of view the influence of family to his/her
behavioural problems/offending;
▪ interpersonal relationships with peers, with boys & girls, friends, neighbors and other
community/youth/children’s groups/organization of which the child is a member
including gang membership; nature and extent of participation in these groups;
▪ previous involvement with drugs, alcohol, gambling, smoking and other similar
activities;
▪ previous contacts with the law, experiences relative to detention, violence,
harassment and abuse by authorities: police, barangay officials, teachers and others
in authority;
▪ behaviour before and after the offense/incident and action taken;
▪ over-all assessment of child’s role performance and social functioning.

B. THE CHILD’S FAMILY

▪ socio-economic condition of the family; access to basic resources (food, health care,
housing, livelihood, employment) and ability to secure such resources (ecomap may
be used); coping with family stressors related to socio-economic situation;
 experiences of oppression and discrimination; involvement in drugs, alcohol,
gambling and other similar activities;
▪ family power structure in relation to economic, social and psychological levels;
violence in the home, if any;
▪ family relationships and roles among members – complementary, reciprocal roles;
may use a genogram); other significant persons in the child’s life who may be able
to provide care and guidance;
▪ family goals shared among family members in addition to their individual goals;
hopes, dreams and aspirations;
▪ communication styles of family members and communication pattern in the family;
▪ family traditions/rituals, patterns of help-seeking behaviour, information how a
problem will be handled, individual and institutions that the family may turn to in
times of difficulty; participation in community affairs;
▪ family decision-making process including self-expression and feedback among
family members;
▪ child-rearing practices and disciplinary measures undertaken by parents and other
significant others in the family;
▪ over-all assessment of parenting capability of father and mother or
guardian/custodian including their awareness of their possible involvement or of
family factors contributory to the child’s behavioural problems or offending; their
willingness to receive child into their care and custody and how they plan to manage
child’s behaviour, if child be released to them; and
▪ family plans and roles, including that of the child, in the diversion/intervention
program.

C. THE CHILD’S COMMUNITY

▪ description of the type of community and neighbourhood in which the child resides
or will reside;
▪ adequacy of housing and other social conditions for child’s physical well-being
including the safety and security of the child;
▪ availability of social services e. g. schools, church, community-based programs
of government/NGOs/faith-based organizations for the prevention of juvenile
delinquency;
▪ community/family/peer/youth groups/associations to support children under the
diversion and intervention programs; and
▪ functionality/active involvement of the SangguniangKabataan and the Local Council
for the Protection of Children in the preventive and rehabilitative programs including
diversion and intervention programs for children in conflict with the law.

V. DIAGNOSTIC STATEMENT/ ASSESSMENT

▪ statement of the problem;

▪ present and past family and environmental factors which contributed to the problem;
▪ family’s internal and external resources;
▪ child’s discernment, criminal liability and participation and resources in
diversion/intervention/rehabilitation programs;
▪ measures undertaken to solve the problem, if any
▪ incorporate your findings using the CANS if utilized the said tool
VI. INTERVENTION PLANS

▪ Problems
▪ Objectives
▪ Interventions
▪ Activities
▪ Persons responsible: specific responsibilities of child, family/guardian and social
worker and others, if any
▪ Time frame
▪ Resources Needed
▪ Expected Outputs

Social Worker:
 Appendix D

REPUBLIC OF THE PHILIPPINES

REGIONAL TRIAL COURT
_________ BRANCH __________
Place No.

Republic of the Philippines,

Plantiff, Crim. Case No. 123
vs.
JUAN DELA CRUZ for
Accused, MURDER
x-------------------------------x

PROGRESS REPORT
(Quarterly)

Name : JUAN A. DELA CRUZ

Age : 17
Sex : MALE
Address : Brgy. 123, Argao, Cebu
Name of Residential Care Facility : Regional Rehabilitation Center for Youth
Date of Admission at the Facility : June 8, 2017
Age upon Commission of the Offense : 16
Length of Stay at the Center : 1 year
Status of the Case : suspended sentence

I. INTELECTUAL/COGNITIVE ASPECT
(This includes the educational background, intellectual capacity, academic performances, and
status in ALS class, formal education and tutorial sessions. Ability to follow routines, policies and
instructions, IQ results)

II. EMOTIONAL/BEHAVIORAL ASPECT

(Findings of the psychologist/psychiatrist, observations of rehabilitation team in terms of
behaviour or attitude towards self, co-residents, staff, families and communities. Residents’
strengths, competencies and potentials among others. Problem solving and decision-making skills.
Own participation in his rehabilitation process, Feelings expressed towards his/her family
members and diagnosis if any,)

III. PHYSICAL ASPECT

(This includes the physical condition and health aspect of the child (personal hygiene, proper
grooming, nutritional status, illnesses, physical deformities, participation to physical fitness
activities, diagnosis, medications and medical procedures conducted if hospitalized.)

IV. SOCIAL ASPECT

(Participation in center’s activities, skills acquired, abilities to make a living,
interaction/communication skills with co-residents and authorities, learned values such as
respect, proper etiquette and dealing with other people/quality of relationship with others)
 V. MORAL ASPECT
(Spiritual aspect of the residents includes participation in all religious activities both in and outside
the center based on their beliefs, his realizations, values manifested, learnings and reflections)

VI. OTHERS
(In the event that misdemeanor was committed during the period, this should be reported to court
with the corresponding action/intervention extended by the Rehabilitation Team and other
pertinent information)

ASSESSMENT/RECOMMENDATIONS: (assessment based on the reports stated above and the next
steps/recommendations to attain the goals or intervention plans.

RRCY, ______________, Philippines

Date:_______________

Submitted by:
________________________
Social Worker/Case Manager
PRC Lic.#______________

Noted by:

________________________________
Center Head
PRC Lic.#___________

Note: Progress report should be submitted to court every three months or quarterly and as prescribed by the
Judge in the Court Order
 Appendix E

(Name of Center)

(Address)

OUT ON PASS SLIP

___________________
Date

The bearer _______________________________________ is to be out on pass from the center from

(Name of Minor)
____________________ until _____________________ for the following purpose/s ___________________.
(Date) (Date)

________________________ ___________________
Client’s Signature Date

________________________ ___________________
Social Worker Date

Recommended by: Approved by:

________________________ __________________________
Supervising Social Worker Center Head
________________________ __________________________
Date Date

RETURN SLIP
This is to certify that I _______________________________________________________ received
(Name of Receiving Party)
_________________________________________________________________, who was out on pass, from
(Name of Parent/ Guardian/ Relatives)
_____________________________________________________________________________________.

_________________________________________ ________________________________
Signature of Receiving Worker Date/ Time
 Appendix F

(Name of Center)

(Address)

OUT ON PASS CONTRACT

Ako si _______________________________________________________, magulang/ kamag-anak ni
(Pangalan)
________________________________, _________ taong gulang ay nagnanais na makasama at makapiling si
(Pangalan ng Bata) (Edad)
____________________________________________, ngayong ika- _________ ng ____________, 200____.
(Pangalan ng bata)
Ako ay nangangako na habang siya ay nasa aking pangangalaga ay sisikapin ko na mapangalagaan
ang kanyang kaligtasan at nasa ligtas na kalagayan. Siya ay aking ibabalik sa center sa __________________
(Petsa)
ayon sa kasunduan. Anumang di inaasahang pangyayari habang siya ay nasa aking pangangalaga ay aking
pananagutan lalo na sa korteng nakakasakop sa kanyang kaso.
Ito ay aking nilalagdaan ng kusang loob ngayong ika ________________ ng ___________________,
200___.

_______________________________________
Pangalan at Pirma ng Magulang/ Kamag-anak

__________________________
Petsa

_______________________________________
Pangalan at Pirma ng Bata

________________________
Petsa

_____________________________
Social Worker

_______________________
Petsa
 Appendix G

(Name of Center)

(Address)

HOUSEPARENT’S ANECDOTAL REPORT

Cottage_______________

Name of Resident:_____________________________________________________ Age:_______________

Date Admitted or Transferred in the cottage/ room:____________________________________________
Category: ____________________________________________________________________________

(Use matrix form if preferred)

OBSERVATIONS:
I. Significant behaviors (Relayed during sessions/dialogues/observed/portrayed during her stay in
the cottage).
A. Positive (Mga positibong pag-uugali, pananaw, mga plano sa buhay, kilos, Gawain, etc.).
___________________________________________________________________________
_________________________________________________________________________.
B. Negative (Mga negatibong ugali, pananaw, mga plano sa buhay, kilos, Gawain, etc.)
___________________________________________________________________________
________________________________________________________________________.
II. Relationship with peers (Paano siya makitungo o makipagkapwa tao sa kasamahan).
_______________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________.
III. Relationship with staff/older people (Paano makitungo sa nakatatanda/ sa staff).
_______________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________.
IV. Actions Taken
_______________________________________________________________________________
_______________________________________________________________________________
V. Recommendations/ suggestions
_______________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________.

Houseparent: ____________________________

Date: ___________________

Note: Other unusual incident/salient observations will be immediately reported in a separate

form.
 Appendix H

(Name of Center)

(Address)

INCIDENT REPORT
Cottage_______________

Name of Minor (Pangalan ng Bata) _____________________________________________ Age__________

Type of incident (Uri ng Pangyayari) __________________________________________________________
Date (Kailan Nangyari) ____________________________________________________________________
What time? (Oras) _______________________________________________________________________

Brief Summary of the Incident: How it happened? Why? (Maikling salaysay tungkol sa pangyayari. Paano?
Bakit? Saan naganap?)
_________________________________________________________________________________________
_________________________________________________________________________________________
______________________________________________________________________________________.

Action Taken (Anong ginawa para sa kapakanan ng bata).

_________________________________________________________________________________________
_________________________________________________________________________________________
______________________________________________________________________________________.

Recommendation/ Suggestion
_________________________________________________________________________________________
_________________________________________________________________________________________
______________________________________________________________________________________.

____________________________
Staff/ Houseparent
 Appendix I

(Name of Center)

(Address)

PRODUCTIVITY SERVICE
Trainer’s Observation Report

Name of Trainee: _______________________________ Age: ___________ Sex: ______________

Date Admitted: ____________________________________________________________________________

OBSERVATIONS :

I. Significant behaviors (inside the classromm)

A. Positive (Positibong pag-uugali na ipinakikita habang nasa silid-aralan)
___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________________________
B. Negative (Negatibong ugali na ipinakikita habang nasa silid aralan)
___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________________________
II. Relationship with classmates
_______________________________________________________________________________
_______________________________________________________________________________
_____________________________________________________________________________
III. Relationship with trainors
_______________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________

____________________________
Trainor

Recommendations and Suggestions:

_________________________________________________________________________________________
_________________________________________________________________________________________
_______________________________________________________________________________________

_____________________________
Manpower Development Officer
___________________
Date
 Appendix J1

(Name of Center)

(Address)

DISCHARGE FORM

____________________
Date

The bearer _____________________________________________________________________

(Name of Child)
Is DISCHARGED to ______________________________________________________________________
(Receiving Party)

_____________________
Client’s Signature/ Date

_____________________
Social Worker

Noted/ Recommended by:

_____________________________________

SERVICES SIGNATURE REMARKS

1. Homelife Service
2. Social Service
3. Medical Service
4. Psychological Service

Approved by:

_____________________________________
Head Social Worker/ Date
 Appendix J2

(Name of Center)

(Address)

RECEIPT OF WARD

____________________
Date

This is to certify that I, ____________________________________________________________of

(Name of Child)
____________________________________________________________________ received the person of
(Name of Receiving Party)
____________________________________________________________________ for discharge this day of
(Address)
______________________________________________________________________ 200____________.

____________________________
Signature of Parent/Guardian/Date

____________________________
Address

Witness: _________________________________________
________________________________________________
Date: _____________________ Time: _________________
 Appendix K1

(Name of Center)

(Address)

VOLUNTEER WAIVER
___________________
Date

I/We (name of the organization/volunteer) has fully understood the rules and regulations of the
Center while performing our voluntary services. That I/we have to abide and observe/follow the
policies and agreements as well as the child protection policy of RRCY that has been stipulated
in the memorandum of understanding.

Further, the Center/Office has no liability and accountability of whatever untoward incidents
occurred or that may happen to me/us at the time that I/we are extending/conducting our
programs and services for the residents.

Signed this (day) of (Month and Year), at (address).

CONFORME:

Name and Signature of the Volunteer

Witness/as: NAME & DESIGNATION

Appendix K2
Appendix K3
Appendix I
Appendix I
Appendix J
Appendix K
Appendix L
Appendix M
Appendix N
Appendix O
Appendix P
Appendix Q
Appendix R
Appendix S
Appendix T