FIELD OFFICE MIMAROPA

CRISIS INTERVENTION SECTION

DSWD-PMB-GF-000 | REV 00 / xx xxx xxxx

GENERAL INTAKE SHEET

MAARING MAGPATULONG SUMAGOT SA DSWD PERSONNEL

QN: PCN: Time Start: Date: 12 29 2022

New Returning On-Site Walk-in Referral Off-Site

IMPORMASYON NG BENEPISYARYO (Beneficiary’s Identifying Information)

Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

SAN AGUSTIN ROMBLON IV-B

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)
MM-DD-YYYY
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Trabaho (Occupation) Buwanang Kita (Monthly Salary)

IMPORMASYON NG KINATAWAN (Representative’s Identifying Information)

Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

SAN AGUSTIN ROMBLON IV-B

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)
MM-DD-YYYY
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Trabaho (Occupation) Buwanang Kita (Monthly Salary)

Relasyon sa Benepisyaryo (Relationship to the Beneficiary) Time End:

Huwag susulatan ang DSWD lamang ang pwede gumamit (Do not write below this part for DSWD's use only)
Beneficiary Category Social worker's Assessment
Target Sector: Specify Sub-Category

FHONA Solo Parents

WEDC Indigenous People
As per assessment, the client's family belongs to indigents in their
YOUTH Recovering Person who used drugs
community and financially challenged to provide the needs for allowance
PWD 4PS DSWD Beneficiary and other school expenses. The family is earning minimum monthly
SC Street Dwellers income and is found to be in crisis. With foregoing facts, therefore, the
PLHIV Psychosocial/Mental/Learning Disability client is eligble for assistance as a provision of the program.
CNSP Stateless Person/Asylum Seekers/Refugees
Others:
KOMPOSISYON NG PAMILYA (Family Composition)
Buong Pangalan Relasyon sa Benepisyaryo Edad Trabaho Buwanang kita
(Complete Name) (Relationship to the Beneficiary) (Age) (Occupation) (Monthly Salary

✘ Financial Assistance: Material Assistance: Psychosocial Support: Referral:

Medical Food Assistance Family Food Packs __________
Psychological First
Funeral Other Food Items Aid (PFA)
__________
Cash Assistance
Transportation for Other Support Social Work __________
Hygiene & Sleeping Kits
✘ Educational Services Counseling
Assistive Device & Technologies
Provided Amount Fund Source
1 EDUCATIONAL ASSISTANCE PSP 2022
2

3
"I declare under oath that I personally accomplished the GIS Form and all the

information provided herewith are TRUE, CORRECT, VALID & COMPLETE pursuant

to exisiting laws, rules and regulations of the Republic of the Philippines. I authorized
Interviewed by: Reviewed & Approved by:
the Agency Head/validate the contents stated herein. I also AGREE that any

MISINTERPETATION and information/acts to DEFRAUD the government including

attached documents shall cause the filling of appropriate case/s against me"

LOREN P. GADIANO ABEGAIL F. FETILO

Buong Pangalan at Pirma Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

_______________________________________________________________________________________________
Page 1 of 1
DSWD Central Office, IBP Road, Batasan Pambansa Complex, Constitution Hills, Quezon City, Philippines 112
Website: http://www.dswd.gov.ph Email: ciu.co@dswd.gov.ph Tel Nos.: 8962-2813 or 8931-8100 local 509,510 Telefax: (632) 931-8191
 FIELD OFFICE-MIMAROPA
CRISIS INTERVENTION SECTION
DSWD-PMB-GF-000 | REV 00 / xx xxx xxxx

CERTIFICATE OF ELIGIBILITY
(Financial Assistance)

QN: PCN: Date: 12 29 2022

New Returning On-Site Walk-in Referral Off-Site

Mal Fem
This is to certify that, , e ale
Kumpletong Pangalan (First name, Middle name, Last name) Kasarian (Sex) Edad (Age)

and presently residing at Brgy. , Romblon

kumpletong Tirahan (Complete Address)

has been found eligible for assistance after assessment and validation conducted, for his/herself or through the representation of his/her

Relasyon ng Kinatawan sa Benepisyaryo (Relationship of the Representative to Beneficiary) Buong Pangalan ng Benepisyaryo (Name of Beneficiary)

Records of the case such as the following are confidentially filed at the Crisis Intervention Section (CIS/SWADT)

✘ General Intake Sheet Medical Certificate/Abstract Discharge Summary Death Summary

Laboratory
Valid I.D. Presented Prescriptions Referral Letter
Request
Statement of Account Charge Slip Social Case Study Report
4PS DSWD I.D. Treatment Protocol Funeral Contract Others
Justification Quotation Death Certificate

The Client is hereby recommended to receive EDUCATIONAL assistance for SCHOOL NEEDS AND OTHER EXPENSES

in the amount of THOUSAND PESOS ONLY Php. CHARGEBLE AGAINST: PSP 2022
(Year)

Conforme: Prepared by: Approved by:

LOREN P. GADIANO ABEGAIL F. FETILO

Beneficiary/Representative Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Acknowledgement Receipt

Date: 12 29 2022

✘ Financial Assistance THOUSAND PESOS ONLY Php

(Amount in words)

Medical Assistance Transportation Assistance Food Assistance

Funeral Assistance ✘ Educational Assistance Cash Assistance for Support Services

Tinanggap ni: Binayaran ni: Sinaksihan ni:

ABEGAIL F. FETILO SHERYL S. CANOY

Beneficiary/Representative RDO / SDO AA IV
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

*E.O 163 series 2022

_______________________________________________________________________________________________
Page 1 of 1
DSWD Central Office, IBP Road, Batasan Pambansa Complex, Constitution Hills, Quezon City, Philippines 112
Website: http://www.dswd.gov.ph Email: ciu.co@dswd.gov.ph Tel Nos.: 8962-2813 or 8931-8100 local 509,510 Telefax: (632) 931-8191