FILADELFIA WOMEN CRISIS CENTRE

Transcription

1 FILADELFIA WOMEN CRISIS CENTRE Personal Details Form A-1 Names first middle last Occupation and/or source of income Date of birth Place of birth Tribe ID number Postal address Residential address Town estate Road/sub-location Phone/ contact number Name of contact Name of guardian or parent Address of the guardian / parent Referred by (organization, private, self- etc.) The client s preliminary impulsive statement/ Cause of admission (describe the incident briefly) Receiving centre staff: Responsible centre staff (case worker): Marital status Photo Day, date and time: Day, date and time: Children No name age F/M stays at Police or any other authority involve or notified? (State who and time of involvement)

2 The Client s Condition at Arrival Form A-2 Description of the client s physical condition (injuries, deformities, hygiene, condition of clothes etc.) Description of the client s mental and psychological condition (crying, angry, body language etc.) Any mental or physical disorder or sickness? (state which kind and if any medicine is required) Any medical assistance or hospitalization in connection with the incident? (where and when. Attach the copy of the hospital s or doctor s statement if possible) Personal information

3 Children accommodated at FWCC Form A-3 Details Child 1 Child 2 Child 3 Child 4 Name (first, middle, last) DOB/age Place of birth Remarks (maladjusted, problems, sickness etc) Name Address Contact details (phone etc) occupation Name Address Contact details( phone etc) Occupation Father Guardian or close relationships (family members, neigbors etc) Name school Address Class Headmaster s name Activity plan when staying at FWCC

4 Belongings Brought Form A-4 Name of the admitted (if a child please put mothers name also)... No item description (To be continued on the next page if necessary) Items no on own responsibility Items no kept by the centre Date and Signature Client Date and Signature FWCC staff

5 Research Relatives Names First middle last Relationship DOB/Age Place of birth tribe ID number Postal address Residential address Town estate Road/sub-location Phone/contact Number Name of contact Names First middle last Relationship DOB/Age Place of birth tribe ID number Postal address Residential address Town estate Road/sub-location Phone/contact Number Name of contact Names First middle last Relationship DOB/Age Place of birth tribe ID number Postal address Residential address Town estate Road/sub-location Phone/contact Number Name of contact Names First middle last Relationship DOB/Age Place of birth tribe ID number Postal address Residential address Town estate Road/sub-location Phone/contact Number Name of contact Form A-5-0

6 Research Background Information Form A-5-1 Conduct of life in chronological order (schools, education, training, childhood, adolescence, jobs, childbirths, epoch-making incidents, traumatic experience etc) Profound description of the incident/ cause of admission (before the incident, during the incident and after the incident) What does the client think is the cause of the incident?

7 Research/Residence Form A-5-2 Description of residence or crime scene (type, location, size, compound, household effects, furniture, security measures) Description of the tidiness and cleanliness Remarks

8 Research/Interviews Form A-5-3 Name First Middle Last Relationship to the case DOB/ Age Place of birth tribe ID number Postal address Residential address Town estate Road/sub-location Phone/ contact number Name of contacts Statement:

9 Consent for Admission Form A-6 I. ID. No.. Have agreed to be sheltered in the Filadelfia Women Crisis Centre FWCC and shall obey all current rules, regulations and directives in respect to the admission. I also admit that the sheltering is a temporary step in my case. I admit that the centre staff will determine the sheltering period within two (2) weeks from this date. During my sheltering, I admit that I shall be bound by the rules and regulations, which have been given to me in printing. date Admitted /client date Social worker date Care taker Management approval Name... Signature Date

10 Agreement Form A-7 Date of sheltering (date of admission to date of expected to leave) Condition of sheltering (participation in cleaning-cookinglaundry etc) Training-courses (State type and duration) Miscellaneous-remarks By my signature I acknowledge the above written and will comply in all conditions and limits mentioned. Name Signature. Date.. Management approval Name.. Signature Date..

11 Items Given Form A-8 Name of admitted (if a child please put mothers name first) No item Date received staff Client s signature

12 Clients Daily Schedule Name of client: Form A-9 Name of client s children involved: Staff member in charge: Week no. Date from to Day no Activities Comments

13