PROTECTIVE SERVICES DIVISION

FIELD OFFICE III

DSWD-PMB-GF-011 | REV 01 / 30 SEPT 2022

GENERAL INTAKE SHEET

MAARING MAGPATULONG SUMAGOT SA DSWD PERSONNEL

PCN: Time Start: QN:Date: 2023

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)

ZAMBALES III
House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)

Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Civil Status (Katayuang Sibil) Trabaho 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)

ZAMBALES III
House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist
Region (Ex. NCR)
III)

Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Civil Status (Katayuang Sibil) Trabaho Buwanang Kita (Monthly Salary)

VALID ID: PAMPANGA

Relasyon sa Benepisyaryo (Relationship to the Beneficiary) REFERRING PARTY: SEN. IMEE MARCOS Time End:
Beneficiary Category Social worker's Assessment
Target Sector: Specify Sub-Category

FHONA Solo Parents

SC Indigenous People
WEDC Recovering Person who used drugs
YNSP 4PS DSWD Beneficiary
PWD Street Dwellers
PLHIV Psychosocial/Mental/Learning Disability
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

ALFRED SANTOS NEPHEW 16 NONE NONE

Financial Assistance: Psychosocial Support: Referral:

Material Assistance: ___________
Medical Food Assistance Psychological First Aid
Funeral
Family Food Packs
(PFA)
___________
Cash Assistance for Other Food Items
Transportation Other Support
________
Hygiene & Sleeping Kits Social Work Counseling
Educational Services Assistive Device & Technologies

Provided Amount Fund Source

1
PSP 2023
2
FOOD ASSISTANCE 3,000
3
-
"I declare under oath that I personally accomplished the GIS Form and all the
information provided herewith is TRUE, CORRECT, VALID, and COMPLETE
pursuant to existing laws, rules, and regulations of the Republic of the Philippines. I
authorized the Agency Head/Authorized Representatives to verify and validate the
contents stated herein. I also AGREE that any MISINTERPRETATION and Interviewed by: Reviewed & Approved by:
information/acts to DEFRAUD the government, including attached documents, shall
cause the filing of appropriate case/s against me."
THUMB MARK

ROSEMARIE M. HEBRON
MERYLL LALAINE C. ROQUE PRC# 016915

Page 1 of 1
Buong PangalanDSWD
at Pirma
Field Office III, Diosdado Macapagal Government Center, Maimpis, City of SanSocial Worker
Fernando, Pampanga, Philippines 2000 Approving Authority
(Signature over Printed Name) Website: http://www.dswd.gov.ph Tel Nos.: (045) 961-2143over Printed Name)
(Signature (Signature over Printed Name)
Huwag susulatan ang DSWD lamang ang pwede gumamit (Do not write below this part for DSWD's use only)
CLIENT'S CATEGORY BENEFICIARY'S CATEGORY
Family Head and Other Needy Adult (FHONA) Family Head and Other Needy Adult (FHONA)
Women in Especially Difficult Circumstances (WEDC) Women in Especially Difficult Circumstances (WEDC)
Youth in Need of Special Protection (YNSP) Children in Need of Special Protection (CNSP)
Senior Citizen (SC) Youth in Need of Special Protection (YNSP)
Persons With Disability (PWD) Senior Citizen (SC)
Persons Living with HIV-AIDS (PLHIV) Persons With Disability (PWD)

Persons Living with HIV-AIDS (PLHIV)

General Intake Sheet PROTECTIVE SERVICES DIVISION FIELD OFFICE III

Part 2 DSWD-PMB-GF-012 | REV 00 | 23 MAY 2022

Sub-Category Sub-Category
Recovering Person Children with Disability
who used Drugs Recovering Person who used Drugs
Indigenous People Indigenous People
OTHERS (specify) OTHERS (specify)

ASSESSMENT (use additional sheets as necessary)

PROBLEM/S PRESENTED: The client is needing financial assistance to help the family secure their daily basic needs that they are struggling to sustain due to lack of existing
resources.

SOCIAL WORKER'S ASSESSMENT:

The client cannot support the presented needs due to his / her family's limited resources brought by current inflation / crisis / financial exhaustion from their other expenses such
as daily basic needs and bills.

RECOMMENDED SERVICES AND ASSISTANCE

Psychosocial Support ✓ Legal Assistance Referral(Specify): ________________________________________

Financial Assistance ✓
AMOUNT OF
TYPE OF ASSISTANCE PURPOSE ASSISTANCE FUND SOURCE DATE PROVIDED

Medical Assistance

Funeral Assistance

Transportation Assistance

Educational Assistance

Food Assistance food and other daily needs 3,000 PSP 2023

Cash Assistance (other

support services)
Provision of PPE

Non-Food Items

Interviewed by: ROSEMARIE M. HEBRON PRC# 016915

MERYLL LALAINE C. ROQUE

Name and Signature of Social
Worker
Reviewed and Approved by:
KOMPOSISYON NG PAMILYA (Family Composition)

Buong Pangalan Relasyon sa Benepisyaryo Edad Trabaho Buwanang kita

1
2

5
 Name and Signature of Approving Name
and Signature of Client
Officer
Thumb Mark