CITY SOCIAL SERVICES DEPARTMENT

SPECIAL SOCIAL SERVICES DIVISION

WOMEN AND CHILD PROTECTION UNIT
RA 9344 JUVENILE JUSTICE AND
WELFARE ACT OF 2006
Tel. no.: (049) 545 6789 local 8120, 8226 & 8022

CASE NUMBER :
BARANGAY :
CITY :
PROVINCE :
DATE :

CICL/CAR FORM 1 – CLIENT CARD CONFIDENTIAL

Form to be completed by fully trained and designated staff. Part I must be filled up at initial
INSTRUCTIONS contact and forwarded to the RecA, while the CM shall accomplish Part II. Attach additional
pages with narrative, if needed. Retain a copy and ensure that confidentiality is observed.
Separate intake sheets are used in accordance with the requirements of the concerned
NOTE agencies. However, there are supplemental information which are needed for the data
base.

PART I. INITIAL INFORMATION

Client Category Child At Risk (CAR) Child in Conflict with the Law
A. Client Profile
Complete Name
Date of Birth Sex Male Female
Place of Birth Physical Disability
Complete Address Civil Status:
Ethnic Background Single
Highest Educational Attainment Married
Occupation “Live-In”
Workplace Address Religion
Current Status of Schooling
In School Last School Attended and Address
Out of School
Not of School Age
B. FAMILY BACKGROUND
*Immediate / Biological Family
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
1 Complete Address 2 Complete Address

Educational Attainment Educational Attainment

Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number
 B. FAMILY BACKGROUND (cont)
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
3 4
Complete Address Complete Address
Educational Attainment Educational Attainment
Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
5 6
Complete Address Complete Address
Educational Attainment Educational Attainment
Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
7 8
Complete Address Complete Address
Educational Attainment Educational Attainment
Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
9 10
Complete Address Complete Address
Educational Attainment Educational Attainment
Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number
*Use additional sheet if necessary
 B. FAMILY BACKGROUND (cont)
*Other household members where the child is presently residing
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
1 2
Complete Address Complete Address
Educational Attainment Educational Attainment
Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
3 4
Complete Address Complete Address
Educational Attainment Educational Attainment
Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
5 6
Complete Address Complete Address
Educational Attainment Educational Attainment
Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
7 8
Complete Address Complete Address
Educational Attainment Educational Attainment
Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number
*Use additional sheet if necessary
 B. FAMILY BACKGROUND (cont)
*Significant Others who may not be staying with the family
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
1 2
Complete Address Complete Address
Educational Attainment Educational Attainment
Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number
Name Name
Sex Sex
Age Age
Civil Status Civil Status
Relationship Relationship
3 4
Complete Address Complete Address
Educational Attainment Educational Attainment
Occupation Occupation
Workplace Address Workplace Address
Contact Number Contact Number

C. REMARKS
Other relevant information on the child’s past and present conditions

D. VIOLATION/OFFENSE OF CLIENT
Violation/Offense Category Date Committed
Specific Violation/Offense Time Committed
Place Committed
Date of Admission Status
Repeat Offender If yes, indicate previous offenses and number of times committed.
Yes
No
 E. CIRCUMSTANCE OF REFERRAL
Name of Referring Party
Address
Contact Number
Offense Allegedly Committed Date
Place
Date of Apprehension Place
Apprehended by Designation
Agency Address Contact Number
Reason for Referral

F. VICTIM INFORMATION
Complete Name Sex Male Female
Complete Address Civil Status
Age Single
Nationality Married
Ethnic Background “Live-In”
Occupation Separated
Workplace Address Widow
Remarks

G. COMPLAINANT INFORMATION
Complete Name Sex Male Female
Complete Address Civil Status
Age Single
Nationality Married
Ethnic Background “Live-In”
Occupation Separated
Workplace Address Widow
Remarks
LAW ENFORCEMENT OFFICER’S REPORT
Attach additional pages with continued narrative if needed.
CHILD’S VERSION
Attach additional pages with continued narrative if needed.
VIEWS OF THE CHILD ABOUT THE OFFENSE COMMITTED
Attach additional pages with continued narrative if needed.
 PART II. ACTION TAKEN
A. Action Taken
Reported to: Date reported: Action taken:
BARANGAY/LOCAL LEADERS Intervention and Prevention Proceeding /
Family Conference
Name: Intervention and Prevention Program
Address: formulated/signed
Contact Number: Diversion Proceeding / Family Conference
conducted
Diversion Program formulated/signed
LAW ENFORCEMENT Receipt and recording of complaints
Rescue operations for VAWC cases
Name: Forensic interview and investigations
Address: Medico-legal exam
Contact Number: Others, please specify:
C/MSWDO Psychosocial
Emergency/Temporary shelter
Name: Economic assistance
Address: Residential facility
Contact Number: Others, please specify:
HEALTH CARE First Aid
Medico-legal exam
Name: Provision of appropriate medical treatment
Address: Issuance of medical certificate
Contact Number: Others, please specify:
PROSECUTOR/LEGAL Legal counselling
Representation in court
Name: Documentation and notarization
Address: Assist in filing of petition for TPO/PPO
Contact Number: Mediation
Others, please specify:
OTHER PERSON/S or INSTITUTION Other service/s provided:
(ie. school, workplace, etc)

Name:
Address:
Contact Number:

Name:
Address:
Contact Number:
 PART III. RECOVERY AND REINTEGRATION PLAN

B. Planned Action (as of date this form is completed)

Psycho-social intervention:
Temporary shelter
Counseling
Legal services
Witness protection
Medical/health services
Alternative care
Temporary residential care
Peer-to-peer activities
Family assessment/orientation
Community education
Educational services
Others:
Economic reintegration program:
Career counseling and occupational guidance
Skills assessment/recognition
Technical/vocational skills training
Livelihood training
Capital Assistance
Access to micro-finance assistance
Job-placement services
Others:

CLIENT’S PRE-REINTEGRATION PLANS

Reunification with family Remarks:
(Indicate any concern expressed by client)
Resettle elsewhere (with relatives/friends, etc.)
Temporary residential care
Seek psychosocial intervention
Seek medical care/assistance
Return to school
Undergo vocational/skills/livelihood training
Engage in a livelihood
Seek local employment
Migrate for overseas employment
File:
Civil Action
Criminal Charges
Labor Claims

__________________________________
Name and Signature of Interviewer/Duty-bearer

__________________________________
Name and Signature of the Child
 CITY SOCIAL SERVICES DEPARTMENT
SPECIAL SOCIAL SERVICES DIVISION
WOMEN AND CHILD PROTECTION UNIT
RA 9344 JUVENILE JUSTICE AND
WELFARE ACT OF 2006
Tel. no.: (049) 545 6789 local 8120, 8226 & 8022

BARANGAY :

CICL/CAR FORM 2 – REFERRAL FOR SERVICE CONFIDENTIAL

This form should be accomplished when referring client for services not provided by own
INSTRUCTIONS
agency. Be specific what services are requested.
As the RefA, please be reminded to attach appropriate documents to the ResA to
NOTE complete the referral. Seal the envelope containing this form and the documents, then
give this to the client to bring RecA.

Case No. Date of Referral

To
Address
Contact Person
Name of Client
Age Male
Sex
Address Female
Name of Family/Guardian Contact Number
Address

Reason/s for Referral

Specific Service/s Requested

Please refer to attached report/intake form/case summary for more information.

Feedback requested and send to Referring Party/Agency:

Address
Contact Person Contact Number

Referred by:

__________________________________
Signature over Printed Name

__________________________________
Designation