Republic of the Philippines
Western Mindanao State University
College of Social Work and Community Development
External Studies Unit
Pagadian City
I. INTRODUCTION
II. GROUP COMPOSITION
a. Name of Worker (Indicate your names here)
b. Name of the Group
c. Location
d. Group Size
e. Age Range
f. Group Members (Indicate the Name)
g. Criteria of Group Membership
h. Type of Group
i. Problem Presented
j. General Goal
k. Specific Objectives
l. Needs of the Group
m. Group Model
n. Time Frame
o. Number of Sessions Conducted
Republic of the Philippines
Western Mindanao State University
College of Social Work and Community Development
External Studies Unit
Pagadian City
DIAGNOSTIC STATEMENT
I. Identifying Information
Name of Client :
Household ID Number :
Sex :
Age :
Date of Birth :
Place of Birth :
Civil Status :
Religion :
Educational Attainment :
Address :
Occupation :
Monthly Income :
Work experiences :
Skills :
Membership in Organization :
Ethnicity :
Contact Number :
Case Category :
II. Synthesis of Background Information
A. Client’s Name
B. The Family
C. The Environment
III. Definition of the Problem
IV. Helping Goals
A. For the Client
B. For the Client’s Family
V. Helping Plans
Prepared by: Reviewed by:
_______________________ _________________________
Social Work-Student Interns Agency Supervisor
Noted by:
_______________________
Faculty Supervisor
Republic of the Philippines
Western Mindanao State University
College of Social Work and Community Development
External Studies Unit
Pagadian City
GROUP RECORDS
I. Individual Diagnostic Statement
A. Identifying Information
Name of Client :
Household ID Number :
Sex :
Age :
Date of Birth :
Place of Birth :
Civil Status :
Religion :
Educational Attainment :
Address :
Occupation :
Monthly Income :
Work experiences :
Skills :
Membership in Organization :
Ethnicity :
Contact Number :
Case Category :
B. Background Information
1. Client
2. Client’s Family
Parents
Siblings
3. Significant Others (if important or related to client’s problem/situation)
4. Client’s Environment (neighborhood, community: physical, social characteristics,
etc.)
C. Definition of Problem
(also called “Problem to be worked,” may not be the same as the Presenting Problem,
the problem that will be the focus of the helping relationship; to be agreed on between
the client and the worker)
D. Helping Goals
( the “ends” desired, i.e., to be achieved at the end of the helping relationship)
E. Helping/ Action Plans
(the “means” to achieve the defined goals, i.e., specific interventions, activities, tasks
that have to be done to achieve the goals; separate those that will involve work with the
client and those that will involve work with the client and those that will involve work
with others
Prepared by: Reviewed by:
_______________________ _________________________
Social Work-Student Interns Agency Supervisor
Noted by:
Republic of the Philippines
Western Mindanao State University
College of Social Work and Community Development
External Studies Unit
Pagadian City
________________________
Faculty Supervisor
GROUP RECORDS
II. Individual Assessment Profile
A. Identifying Information
Name of Client :
Household ID Number :
Sex :
Age :
Date of Birth :
Place of Birth :
Civil Status :
Religion :
Educational Attainment :
Address :
Occupation :
Monthly Income :
Work experiences :
Skills :
Membership in Organization :
Ethnicity :
Contact Number :
Case Category :
B. Problem to be Worked
C. Helping Goals
(“ends” to be achieved or expected results/outputs)
D. Helping Plans
(“means” to achieve desired goals/ results)
Prepared by: Reviewed by:
_______________________ _________________________
Social Work-Student Interns Agency Supervisor
Noted by:
_______________________
Faculty Supervisor
Republic of the Philippines
Western Mindanao State University
College of Social Work and Community Development
External Studies Unit
Pagadian City
GROUP RECORDS
III. Group Profile
A. Name of Group
B. Members
(list complete names and nicknames if any)
C. Group Information
: when organized/ first meeting; how the group was formed (e.g., the members sought
agency assistance? Did agency worker reach out to the informally organized group to
offer group services?); venue for sessions, schedule; time frame (if known); other
pertinent data.
D. The group’s Concern/ Problem to be Worked
(may or may not be the Presenting Problem; mutually defined by group members and
social worker)
E. Group Goals
(the “ends” to be pursued; what group and worker expect to have been achieved at the
end of the helping relationship)
F. Helping Plans. Action Plans
(the “means” to achieve the defined goals, i.e., the interventions, activities (including
known program media) and tasks that have to be done to achieve the groups goals;
separate action plans that will involve direct work with the group from action plans that
will involve work with others, e,g. institutional staff, community leaders,etc.)
Prepared by: Reviewed by:
_______________________ _________________________
Social Work- Student Interns Agency Supervisor
Noted by:
________________________
Faculty Supervisor
Republic of the Philippines
Western Mindanao State University
College of Social Work and Community Development
External Studies Unit
Pagadian City
GROUP RECORDS
IV. Group Session Recording
A. Name of Group
B. Date and Time of Session
C. Name of Worker
D. Name of Group Leader
E. Attendance
(list names but not necessary if worker has a check-list type attendance form)
F. Preparations for this Session
(e.g., worker borrowed a video-tape as a “trigger” for group discussion)
G. Agenda
H. Content of Session
(can be a Session Summary, or a Process Recording of Session, depending on what
worker is able, or prefers, or is required to do)
How session started
(e.g., was it difficult to start the session, or was the group spontaneous? What
attitudes/behaviors were displayed?
The theme/topic/concern to be taken up in this session
(e.g., how was it handled, what questions/ points were raised, how did members
interact with each other and with worker, note significant member attitudes, behaviors
and actions observed by worker, including leaders, isolates, cite any important
developments relating to group structure and group processes, etc.; cite specific worker
interventions such as during conflicts, if any; group response to the program media or
activity
Significant results/ outputs from the session
Other matters/ Issues and Concerns
I. Plans for Next Session
J. Insights/ Comments on this Session
(analytical/ evaluative/interpretive comments about what happened during the session)
Prepared by: Reviewed by:
_______________________ _________________________
Social Work-Student Interns Agency Supervisor
Noted by:
________________________
Faculty Supervisor
Note: Include here the Full Package Documentation that Includes
Photo with Caption
Minutes of the Session
Attendance
Republic of the Philippines
Western Mindanao State University
College of Social Work and Community Development
External Studies Unit
Pagadian City
Programme (if there’s any)
Certificates (if there’s any)
GROUP RECORDS
V. Group Evaluation Forms
Individual Member Terminal Evaluation Form
A. Name of Group Member
B. Problem to be Worked
(from Diagnosis Statement or Individual Assessment/Profile)
C. Goal Achievement
(an objective statement of whether or not the defined goals were achieved; a description
of the progress made by client in relation to the “ends” desired for him/her at the end of
group membership, cite concrete/observable indicators to support claim of goal-
achievement, whether full or partial; explain “failure” if any, in goal-achievement and
corresponding plans. Recommendations)
D. Other Goal-Related Work Undertaken
(cite other worker interventions relating to a clients problem/situation, if any, e.g., work
with family, members, employer, etc.; describe changes that took place that were
beneficial to client, etc.)
E. Recommendation/Plans for Follow-Up
Prepared by: Reviewed by:
_______________________ _________________________
Social Work-Student Interns Agency Supervisor
Noted by:
________________________
Faculty Supervisor
Republic of the Philippines
Western Mindanao State University
College of Social Work and Community Development
External Studies Unit
Pagadian City
Group Terminal Evaluation Form
A. Name of Group
B. Group Members
(List names and attendance record od each, if pertinent)
C. Number of Sessions
D. Date and Time
E. Venue
F. The Group’s Concern/ Problem
(as stated in Group Profile)
G. Program Activities Undertaken
(List program media used in each session)
H. Goal Achievement
(describe groups progress/ movement from start to end of group fife in the context of
the group goals stated in the Group Profile; cite concrete/ observable indicators of
success/ effectiveness of the group, and of the helping relationship with the group,
support claim of group goal achievement including feedback from relevant sources, e.g.
family members, teachers, cottage staff, etc.
I. Recommendation/ Plans for Follow-Up
Prepared by: Reviewed by:
_______________________ _________________________
Social Work-Student Interns Agency Supervisor
Noted by:
________________________
Faculty Supervisor
Republic of the Philippines
Western Mindanao State University
College of Social Work and Community Development
External Studies Unit
Pagadian City
Transfer Summary
A. Name
(Individual client or group being transferred to another worker)
B. Problem Addressed
(briefly describe the concern/ problem of the individual client of the group that was the
focus of the helping relationship)
C. Helping Goals Pursued and Interventions Undertaken
( state, which goals have been achieved/ not achieved; explain how/ why, state
significant events/occurrences, concerns/ problems that the next worker should know to
guide her in her work with the client/ group; cite specific, important interventions
undertaken and any pertinent concerns)
D. Recommendations
Prepared by: Reviewed by:
________________________ _________________________
Social Work- Student Interns Agency Supervisor
Noted by:
________________________
Faculty Supervisor
