FORM 1

Case No. ______________

Date of Intake______________

Intake Form

(Data may be obtained from the child and/or significant others.)

I. Identifying Data of the Child

Name:__________________________ Alias, if any _________________________

Sex:_______ Age: ______ Civil Status: _________________

Date of Birth: ___________ Birth Status: ______ Place of Birth:_________________

Religious Affiliation:________________ if IP, please specify: ___________________

Physical Disability(if any) ________________________________________________

Identifying marks (if any) ________________________________________________

Present Address: ______________________________________________________

____________________________________________________________________

Provincial Address: ____________________________________________________

____________________________________________________________________

Highest educational attainment: _________________________________________

Last school attended: __________________________________________________

Date/Year: _________Status: __________In-school _____________OSY__________

Address of school: _____________________________________________________

II. Family Composition

A. Immediate Family

Name Age Relationship Civil Address Educ. Occupation Monthly Remarks

to the child Status Attainment Income

B. Other Household members

Name Age Relationship Civil Address Educ. Occupation Monthly Remarks

to the child Status Attainment Income

C. Significant Others who may not be staying with the family

Name Age Relationship Civil Address Educ. Occupation Monthly Remarks

to the child Status Attainment Income
 D. Remarks (other relevant information on the child’s past and present)

____________________________________________________________

___________________________________________________________________

___________________________________________________________________

III. Circumstances of Referral

(Information could be obtained from the law enforcement officer or
accompanying party)

Name of referring party:______________________________

Address: ____________________Contact No._____________
Reason(s) for referral:________________________________
Date of Referral: ____________________________________
Offense Allegedly Committed: _________________________
Date and Place Where Offense was allegedly committed:
__________________________________________________
Date of apprehension: ___________ Place _______________
Apprehended By: ___________________________________
Name
Designation_________________________________________
Agency/Address: ____________________________________
Contact No.: ________________________________________
Name of Victim (if applicable) __________________________
Age: _____ Sex: _______ Address: ______________________
Contact No.: ________________________________________
Relationship to the CICL _______________________________
 Name of Accompanying Person ( if applicable):
___________ Relationship: __________________________ Age: ____________
Address: _________________________________________
Contact No.: ______________________________________

IV. Problem Presented

A. Law Enforcement Officer’s Report
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
B. Child’s Version
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Views of the child about the offense allegedly committed:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
V. Initial Assessment and Recommended Action
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________

Name and Signature of Social Worker

_________________
Date
 Republic of the Philippines
CITY SOCIAL WELFARE & DEVELOPMENT OFFICE
City Hall Compound, Tacurong City
Telephone No. 064-200-4915

SPIRITUAL ENRICHMENT CARD

_______________
Month

NAME: ________________________________________________________________
ADDRESS: ______________________________________________________________

NAME & SIGNATURE

MASS SCHEDULE TIME AND DATE
(Parish Priest or Lay Ministers)
1st Week
2nd Week
3rd Week
4th Week
Special Occasions

Note: This is a requirement of the Intervention Program pursuant to Chapter 2 OF Republic Act No. 9344
(An Act Establishing a Comprehensive Juvenile Justice and Welfare System, Creating the Juvenile Justice
and Welfare Council under Department of Justice, Appropriating funds therefore and for other
purposes).

___________________________________

City Social Welfare & Development Officer

 Republic of the Philippines
City of Tacurong

CITY SOCIAL WELFARE AND DEVELOPMENT OFFICE

Milanio M. Guerrero
Presiding Judge
RTC Branch XX
City of Tacurong

Sir:

Respectfully submitting herewith the Periodic Report of CICL re: ____________,

charged of the Offense of Rape under Criminal Case No. 2691 in compliance with his Court Diversion
Program.

For your information and ready reference.

Very truly yours,

NANCY M. BAWE, RSW

Social Welfare Officer III
CSWD City of Tacurong

MELBA G. SOURIBIO, RSW

Social Welfare Officer II
DSWD Field Office XII
 Republic of the Philippines
City of Tacurong

CITY SOCIAL WELFARE AND DEVELOPMENT OFFICE

THE PEOPLE OF THE CRIM. CASE No. 2691

PHILIPPINES

Plaintiff

-versus- for

JOSEPH_______ -RAPE-
Accused
X_______________X

PERIODIC REPORT
The undersigned respectfully submits the progress report on the Diversion Program
undertaken by CICL JOSEPH ____________, to wit:

1. The CICL works as a construction worker and receiving an amount of P150.00 daily
which unfortunately could not suffice for their daily subsistence thus his live-in partner
engage in a selling of native delicacies in their area.

2. He is presently a father to a boy, Jomar Cantago

3. He is trying his best to avoid peers of questionable character and working hard to
save for his family.

4. The CICL had continuously shown good performance in complying his diversion
program.

5. The undersigned is trying to convince the CICL to spare some amount and give it to
the office in an installment basis for the payment of his civil liability.

NANCY M. BAWE, RSW MELBA G. SOURIBIO

Social Welfare Officer III Social Welfare Officer II
CSWD-City of Tacurong DSWD Field Office XII
 Republic of the Philippines
Supreme Court
REGIONAL TRIAL COURT
12TH Judicial Region
BRANCH 20
TACURONG CITY

THE PEOPLE OF THE CRIMINAL CASE NO. 2691

PHILIPPINES
Plaintiff -for-
-versus- “R A P E”

JOSEPH_________
Accused,
x__________________x
DIVERSION CONTRACT
For the best of Joseph_________, a child in conflict with the law, the following shall be
undertaken.

FOR THE CICL: Joseph

1. Joseph_______ graduated from the Grino High School on 2003 and a resident
of Tanawing Pag-asa, Brgy. Grino, Tacurong City, Sultan Kudarat;

2. That being a Catholic by religion he shall go to mass every Sunday and get a
mass card monitored by the City Social Welfare Officer of the City of
Tacurong, Sultan Kudarat;

3. That he is a farm helper of his brother in law and has the desire to continue higher education;

4. That he shall avoid drugs and intoxicating liquor and going with persons of
unquestionable character;

5. That he shall involve himself in vocational skills and development programs;

6. Do community service and involve himself in sports and youth program at

Brgy. Grino, Tacurong City, Sultan Kudarat where he is residing in coordination
with the Barangay Chairman of Brgy. Grino, Tacurong City, Sultan Kudarat;

7. He shall avail of the provisions of the Barangay Financial Assistance Program to augment his
Income and skills training program of TESDA.

8. He shall report to the City Social Welfare Officer every first Monday of the month for
Evaluation and effectiveness of the program and;

9. That he shall pay the civil liability to the victim Gene Ann B.________ in the amount of
P50,000.00 as civil indemnity and p50,000.00 as moral damages.

-page 2 follows-
 - page 2 –

DIVERSION CONTRACT
CRIM. CASE NO. 2691

FOR THE CHILD’S PARENTS:

1. To accompany their child for his monthly session with the City Social
Welfare Officer, Tacurong City every first Monday of the month for
Guidance and counseling; and

2. That his parents are willing that Joseph________ will continue his
his education.

FOR THE CITY SOCIAL WELFARE OFFICER, TACURONG CITY

1. To see to it that the CICL Joseph______ reports every first Monday
of the month for his guidance and counseling.

2. That the City Social Welfare Officer will coordinate with the Barangay
Chairman of Brgy. Grino, Tacurong City to monitor the activities of the
CICL Joseph____ where he is residing.

3. Vocational and skills training for the CICL Joseph____, and

4. That she shall monitor compliance and to submit her periodic report
Regularly to the court regarding CICL Joseph____

This contract has been signed this ____day of _____ at Regional Trial
Court, Branch 20, Tacurong City, Sultan Kudarat.

JOSEPH _________________ FAUSTINO______________ and

CICL Parents

ANITA _____________________
Parents

GENE ANN_____________ SPS. ___________________and

Offended Victim MARY ANN__________________
Parents

EUFEMIA ROBLES/NANCY BAWE MR. ROMEO PANES

City Social Welfare Officer Brgy. Chairman
Tacurong City, Sultan Brgy. Grino, Tacurong City,
Sultan Kudarat

Noted by:

PELAGIO C. HILARIO, JR. MRS. ENGRACIA J. YSULAT

Chairperson DSWD, Tacurong City,
RTC-Branch 20, Tacurong City, Sultan Kudarat
Sultan Kudarat

RENATO P. CONSEBIT ATTY. JACQUES JOJIT V. BELEN

City Prosecutor Counsel for the Accused
Tacurong City, Sultan Kudarat Tacurong City, Sultan Kudrat
 REPUBLIC OF THE PHILIPPINES
REGIONAL TRIAL COURT
12TH Judicial Region
BRANCH 20
Tacurong City

Cel no. 09062357379; Telof No. 064-384-1233

And SKTI No. 064-200-4200

THE PEOPLE OF THE CRIM. CASE NO. 2691

PHILIPPINES

Plaintiff,

-versus- -for-

JOSEPH_________, “ R A P E”
Accused,
x______________x

ORDER
The periodic report dated June ________ submitted by Nancy M. Bawe,
RSW, Social Welfare Officer 1, CSWD- City of Tacurong and Melba G. Souribio,
RSW, Social Welfare Officer
II, DSWD Field Office XII, Tacurong City on the progress report on the Diversion
Program undertaken by CICL Joseph_______ is hereby noted.

IT IS SO ORDERED.

Given this ___ day of ______ at Tacurong City, Sultan Kudarat,

Philippines.

MILANIO M. GUERRERO
Judge