Beneficiary Intake| Ina-Inakay Center Inc.

Step 1 of 4

Household Information

Impormasyon ng pamilyang pinaglilingkuran / Information about the household being referred

Beneficiary First Name (Unang Pangalan)* Required / Kinakailangan

Beneficiary Last Name (Apelyido)* Required / Kinakailangan

Age (Edad)

Gender (Kasarian)

Civil Status (Katayuang Sibil)

Number of Children (Bilang ng Anak)

Relationship to Children (Relasyon sa mga Bata)

PDL Status (Katayuan bilang PDL)*

Referral Source (Pinagmulan ng Referral)

Referred By, Name & Position (Sino ang Nag-refer, Pangalan at Posisyon)

Step 2 of 4

Needs Assessment

Pag-aaral ng pangangailangan / What kind of help is needed?

Type of Need (Uri ng Pangangailangan, Check all that apply / Piliin lahat ng angkop)*

Brief Description of Situation (Maikling Paglalarawan ng Sitwasyon)* Please describe the situation / Ilarawan ang sitwasyon

Level of Urgency (Antas ng Pangangailangan)

🔴 Immediate / Agaran 🟡 This Week / Sa Linggong Ito 🟢 This Month / Sa Buwang Ito

All information submitted is treated with strict confidentiality and used solely to determine appropriate assistance. Lahat ng impormasyon ay pinananatiling kumpidensyal at gagamitin lamang para matukoy ang angkop na tulong.

Step 3 of 4

Location & Contact

Lokasyon at pakikipag-ugnayan / Where can we find and reach this household?

Barangay* Required / Kinakailangan

Municipality / City (Bayan / Lungsod)* Required / Kinakailangan

Province (Lalawigan)

Region

Landmark / Directions (Palatandaan / Direksyon)

Contact Number (Numero ng Telepono)

Best Time to Visit (Pinakamainam na Oras)

Additional Notes for PCLL Team (Karagdagang Tala para sa Koponan)

Step 4 of 4

Review Case Summary

Suriin bago isumite / Review all information before submitting the referral

Household Information / Pamilya

Name / Pangalan

-

Age / Gender

-

PDL Status

-

No. of Children / Anak

-

Referred By / Nag-refer

-

Referral Source

-

Needs Assessment / Pangangailangan

Type of Need / Uri ng Tulong

-

Situation / Sitwasyon

-

Urgency / Apurado

-

Location / Lokasyon

Address

-

Contact / Best Time

-

Landmark / Directions

-

I certify that the information provided in this referral is accurate to the best of my knowledge. I understand this referral will be reviewed by the Ina-Inakay Center Inc. team.
Ninapatunayan ko na ang impormasyon sa referral na ito ay tama at totoo sa abot ng aking kaalaman. Naiintindihan ko na ito ay susuriin ng koponan ng Ina-Inakay Center Inc.

Beneficiary Intake Tool