Record No.

______
Date: _____________

Republic of the Philippines

Province of ___________________
City/Municipality of ___________________
____________________________________

INTAKE SHEET FOR CHILDREN IN CONFLICT WITH THE LAW (CICL) AND CHILD AT RISK (CAR)

Client Category: _____ Child At Risk (CAR) _____ Child in Conflict with the Law (CICL)

PROFILE OF CICL/CAR
Personal Information
Name
Last Name First Name Middle Name Extension
Nickname/Alias Nationality

Age Disability

Sex Contact Number

Gender Educational Attainment

Birthdate Educational Status

Civil Status

IP Group

Religion

Address
Lot#/Blk#/Phase/House# Street/Zone Barangay Municipality/City/District

FAMILY BACKGROUND

Name
Last Name First Name Middle Name Extension

Relationship Educational Attainment

Age Sex Employment

Civil Status Contact No

Name
Last Name First Name Middle Name Extension

Relationship Educational Attainment

Age Sex Employment

Civil Status Contact No

Name
Last Name First Name Middle Name Extension

Relationship Educational Attainment

Age Sex Employment

Civil Status Contact No

VIOLATION OFFENSE OF CICL/CAR
Violation/Offense Category Date Committed

Specific Violation/Offense Time Committed

Place Committed
Lot#/Blk#/Phase Street/Zone Barangay Municipality/City/District
Date of Admission
Status
_____ Yes If yes, indicate record number of previous offenses:
Repeat Offender?
_____ No
Record Details

COMPLAINANT
Name Sex

Alias, if any Birthdate

______ Yes
Victim? Relation Contact Number
______ No

Address
Remarks

SERVICES (use other sheets for additional services provided)

____ Center/Residential-based Program
Type Service
____ Community-based Program
Date Provided Date Completed
REFERRAL

Region
Referred to
Province

City
Date Referred
Barangay
Reason for Referral

Name and Signature of Interviewer/Duty-bearer Name and Signature of the Child