INTAKE SHEET

June 6, 2022
Date of Intake
Name: John Carlo Palia Perigrino

Address: P4, Brgy. Quirino, Solano, Nueva Vizcaya

Age: 14 Sex: Male Civil Status: Single

Date of Birth: 2/3/2008 Place of Birth: VRH Bayombong, Nueva Vizcaya

Nickname: CJ

Category: CICL

FAMILY COMPOSITION:

Name Age Relationship Occupation Remarks

Edward S. Perigrino 33 Father Construction
Worker
Analyn Palia 37 Mother Labandera

Jay-R P. Perigrino 9 Brother Pupil – Grade

3
Jonald P. Perigrino 6 Brother Pupil – Grade
1
Jonel P. Perigrino 5 Brother Pupil –
Kinder

PROBLEM PRESENTED: Jerome Jr. was apprehended on June 4, 2022. He was charged for allegedly
involved in Robbery. He was referred by the Bambang Police Station.

ASSESSMENT: This is a case of a minor who was accused of Robbery. Minor voluntarily admits the
crime charged against him hence had submitted himself to undergo Diversion Program at MSWD Solano,
Nueva Vizcaya.

INTERVENTION PLAN:

Activities Resp. Person Time Frame Expected Output

Prepared by:

XILCA MIGNONETTE D. POBRE

SWO-I
Noted:
MIRIAM F. PINAROC
MSWDO