CITY SOCIAL WELFARE AND DEVELOPMENT OFFICE

INTAKE SHEET
Date:_____________

Category: _____ RA 8552/11642 Domestic Adoption ____ RA 11222 Birth Simulation Rectification Act
_____ RA 8043 Inter-Country Adoption

IDENTIFYING INFORMATION
A. CHILD (ADOPTEE)
Name (First/ Middle/ Last name):_________________________________ Age/ Sex:_________________________
Date of Birth:________________ Place of Birth:______________________ Birth Status:______________________
Educational Attainment:_________________ Name of School:___________________________________________
Present Address/ Whereabouts:___________________________________________________________________
B. BIRTH PARENTS
B.1 BIRTH FATHER
Name (First/ Middle/ Last name):_________________________________ Age/ Sex:_________________________
Date of Birth:________________ Place of Birth:______________________ Civil Status:______________________
Date of Marriage (If applicable):________________ Place of Marriage:___________________________________
Educational Attainment:_________________ Name of School:__________________________________________
Occupation/ Name of Company / Monthly Income:___________________________________________________
Present Address/ Whereabouts:__________________________________________________________________
B.2 BIRTH MOTHER
Name (First/ Middle/ Last name):_________________________________ Age/ Sex:_________________________
Date of Birth:________________ Place of Birth:______________________ Civil Status:______________________
Date of Marriage (If applicable):________________ Place of Marriage:___________________________________
Educational Attainment:_________________ Name of School:__________________________________________
Occupation/ Name of Company / Monthly Income:___________________________________________________
Present Address/ Whereabouts:__________________________________________________________________
C. PROSPECTIVE ADOPTIVE PARENTS
C.1 ADOPTIVE FATHER
Name (First/ Middle/ Last name):_________________________________ Age/ Sex:_________________________
Date of Birth:________________ Place of Birth:______________________ Civil Status:______________________
Date of Marriage (If applicable):________________ Place of Marriage:___________________________________
Educational Attainment:_________________ Name of School:__________________________________________
Occupation/ Name of Company / Monthly Income:___________________________________________________
Present Address/ Whereabouts:__________________________________________________________________
C.2 ADOPTIVE MOTHER
Name (First/ Middle/ Last name):_________________________________ Age/ Sex:_________________________
Date of Birth:________________ Place of Birth:______________________ Civil Status:______________________
Date of Marriage (If applicable):________________ Place of Marriage:___________________________________
Educational Attainment:_________________ Name of School:__________________________________________
Occupation/ Name of Company / Monthly Income:___________________________________________________
Present Address/ Whereabouts:__________________________________________________________________
II. FAMILY COMPOSITION
A. BIRTH FAMILY
Name Age/ Sex Civil Status Relationship Educ’l Occupation/ Name of
Attainment employer/company/
Monthly Income

B. ADOPTIVE PARENTS
Name Age/ Sex Civil Status Relationship Educ’l Occupation/ Name of
Attainment employer/company/
Monthly Income

III. WORKER’S FINDINGS/ ASSESSMENT:

IV/ ACTION TAKEN

IV: RECOMMENDATIONS

Prepared by:

NORJINA N. VERGARA, RSW

SWO/ Adoption Social Worker

Noted by:

MA. TERESA O. BRIONES, RSW, MSSW

City Gov’t Dep’t Head II